As Robert Capa’s famous photography maxim goes: “If your pictures aren’t good enough, you’re not close enough.” Each year, Partners In Health (PIH) photographers show patients and staff in moments of hardship and celebration. To do so, we have to get close: into the communities where the work happens and into the lives improved by access to care.

Getting close is a hallmark of PIH’s mission of solidarity and accompaniment. Most PIH staff come from the communities they serve, giving back to their friends, neighbors, and families. Here’s just one example: In August, I photographed Community Health Worker Annie Jere as she conducted a home visit near the hospital in a remote village in Neno District, Malawi. She visited Milica Steven and her three children, screening the family for health concerns as the Stevens’ chickens pecked grain off the dusty path. In the above photo, Jere does a MUAC test for malnutrition, measuring one child’s mid-upper arm circumference. After the visit we walked a few houses away back toward the hospital, then Jere stopped, greeting two young girls in colorful attire. They were her daughters. We were right outside their house.

Here are some of the other images that spoke to us this year.

— Thomas Patterson, PIH photo editor

Zack DeClerck, production manager at PIH: “Photographing Paul Farmer’s memorial service in Boston was incredibly emotional. Not only had we lost a dear friend, mentor, and visionary, but it was also the first time many of us at PIH had seen one another since the start of the COVID-19 pandemic. Watching colleagues, family, patients, and longtime PIH supporters embrace each other throughout the day was truly in the spirit of what Paul taught so many of us about accompaniment. I know I wasn’t alone in sharing the lump in my throat while Dr. Anthony Fauci struggled to finish his remarks about Paul’s impact on his life.” Photo by Zack DeClerck / PIH 

Mélissa Jeanty, multimedia specialist at Zanmi Lasante, PIH's sister organization in Haiti: “When I got to the town square in Mirebalais, many had already gathered for the march in honor of Paul Farmer. Everyone was quiet. Some people were waiting and others were distributing candles and armbands. The communications team consulted earlier in the week regarding what message to print on these armbands. The [Hôpital Universitaire de Mirebalais] staff eventually settled for “Polo, nanm ou ap toujou rete,” meaning “[Uncle] Paul, your soul will live on forever”.

These very words came alive throughout the march. Those in attendance, whether from the hospital or from the community, sang and walked in a way that expressed the deep loss and sadness they felt over Paul's passing, but also the deep love and respect they all held for him.

As I walked among them that day, I could hear the grief in their voices. I could truly feel the desire they all shared to honor Paul Farmer's work and legacy in Haiti.” Photo by Mélissa Jeanty / PIH

Paola Rodriguez, communications coordinator at Compañeros en Salud, as PIH is known in Mexico: “For me, taking pictures means connecting with whoever is on the other side of the lens. Whether it's a staff member, a patient, or even the mountains! It brings me a feeling of gratitude when people share their stories and immortalize a moment and their essence while wearing a big smile. Pictures are also the way we share our reality with the rest of the world.

I met Límbano before because he runs a laundromat where I used to wash my clothes, and I knew it closed for a couple of months because he was ill. I felt joy when he came back and learned that he was a patient at the respiratory disease center where Compañeros En Salud staff work, so we decided to interview him. Although I knew his name and had talked to him briefly before, interviewing him allowed us to connect on a deeper level. He opened up to me with his vulnerability, but also his strength and love, which is something I cherish so much.

At the end of the interview I asked to take his portrait outside of his house, and the dogs he feeds immediately came to him. I could tell they were happy to see him. I wanted to include the dogs in the picture because they were part of what he told me is important to him.” Photo by Paola Rodriguez / PIH.

Jason Amoo, former communications specialist at PIH Liberia: "Like every interaction with beneficiaries, capturing Saturday and Johnson was very inspiring. Their bond and joy were infectious and thankfully that came across in the pictures. Photographing them required little effort because they naturally had a good relationship and all I had to do was capture the essence of it.

For two strangers who have now become inseparable, it was beautiful to see how they cared for and supported each other to overcome challenges presented by their medical conditions. It also goes to prove that making health care available and accessible to all is a human right and the key to building resilient communities." 

Diego Diaz Catire, communications professional at Socios En Salud: "Being part of the photo team at Socios En Salud has very important value and meaning in my life. It is the opportunity to learn about the reality and stories of many people, Peruvian brothers and sisters, who despite the needs and difficulties of their environment, always convey a strong feeling of hope and strength to get ahead. It's with our committed team, which I am proud of, that we can generate positive changes, strengthen the health system, and provide dignified and quality care for thousands of lives." 

Health workers this week launched a new cholera vaccine campaign, hoping to slow, and ultimately end, the current outbreak that has quickly spread throughout Haiti.

The weeklong campaign is led by the national Ministry of Health and Population (MSPP) with support from a team at Zanmi Lasante (ZL), Partners In Health’s sister organization in Haiti. The effort has so far reached more than 4,900 residents of the Mirebalais region in central Haiti and is expected to ultimately deliver a single dose of the oral vaccine, Euvichol-plus, to all eligible residents, about 105,390 people, health officials said. So far, nearly half of the vaccines administered have been to people over 15 years old, with the rest given to younger children.

"The goal is to vaccinate the whole commune with one dose of [the cholera vaccine] in order to reduce and stop the Vibro cholerae," said Dr. Ralph Ternier, ZL's director of programs, using the bacteria's scientific name and noting that many of the workers involved in the current campaign were the same people that fought the outbreak in 2010.

"The community health workers were successfully deployed and after four days we expect to reach one-third of the population," Ternier said. "ZL will put all the efforts to reach the target by the deadline" of December 28.

At the same time, the ZL team continues to treat cholera patients—3,000 people so far— at several facilities while grappling with chaotic conditions, such as widespread kidnappings and shortages of fuel, around the country. At the Hôpital Universitaire de Mirebalais (HUM), 80 beds for cholera patients quickly filled up and cholera treatment units at six other sites, including St-Marc, Petite Riviere, Verrettes, Jean-Denis, Boucan Carre, and Lascahobas, were established to care for additional patients.

As of December 19, Haiti’s MSPP reported 17,629 suspected cases of cholera, 14,972 hospitalizations, and 316 deaths.  The majority of cases continues to be children under 5 years old, who are particularly at-risk due to widespread malnutrition, which leaves young immune systems more vulnerable to disease, physicians said.

Even as cholera surges around the world, the global vaccine stockpile has been depleted, according to the World Health Organization. That means the vaccine is currently being rationed; it is typically given in two doses, but since mid-October, health officials overseeing the global distribution of vaccines made the decision to recommend only one dose to stretch supply. One dose of the vaccine provides between six and 24 months of immunity, while the two-dose regimen delivered four weeks apart gives four years of protection. ZL-led cholera vaccination campaigns in recent years have included a two-dose regimen.

Cholera is caused by drinking water or eating food from sources that have been contaminated with the bacterium Vibrio cholerae. It is found and spread in places where people have inadequate or no access to sanitation and clean water.

People infected with cholera develop watery diarrhea, vomiting, and leg cramps. They can become dehydrated rapidly, go into shock, and may die within 24 hours if they do not receive care.

Cholera was not detected in Haiti until after the 2010 earthquake, when it was inadvertently introduced by United Nations security forces, sickening 820,000 people and causing nearly 9,800 deaths. After multiple, successful mass vaccination campaigns led by ZL and others, and a decision by the World Health Organization to create a cholera vaccine stockpile, cholera was declared eliminated from Haiti in February 2022.  In late September, a new outbreak began in Port-au-Prince, quickly spreading throughout the country.

Looking back, 2022 was a tumultuous year for Partners In Health, marked by tragedy and resilience. 

As we mourned the passing of Dr. Paul Farmer and celebrated his life, we found strength and inspiration in his legacy, reflected in the millions of lives he touched and PIH’s continued lifesaving work around the world. 

Our media coverage and events this year honored that legacy. From penning op-eds in national newspapers to proposing unprecedented global health policy, we continued to advocate for what Paul so eloquently called “a preferential option for the poor”—fighting for all patients, everywhere, to have access to the same treatment we would want for our loved ones. 

In case you missed it, here are some of our favorite moments from 2022: 

1. The Boston Globe: “The White Nationalist Threat to Antiracist Medicine in Boston”  

In January, PIH board member Dr. Michelle Morse and PIH staff Dr. Bram Wispelwey, two physicians within the Division of Global Health Equity at Boston’s Brigham and Women’s Hospital, were targeted by white nationalists for practicing antiracist medicine. PIH CEO Dr. Sheila Davis and Co-founders Dr. Paul Farmer and Ophelia Dahl wrote an op-ed in The Boston Globe to express solidarity with their colleagues.  

They also used that opportunity to reexamine how social pathologies such as racism, neocolonialism, and structural violence continue to affect the health of historically marginalized people, making PIH’s fight for global health equity and social justice even more critical. Read the full piece. 

2. The Atlantic: “There Will Never Be Another Paul Farmer”  

The sudden passing of Paul Farmer in February was a shock for all of us, including people from all walks of life around the world. Paul was so many things to different people—the good doctor, the Harvard professor, the scholar, the global health equity icon and visionary. But to everyone, he was an amazing human being driven by boundless compassion, advocating for a preferential option for the poor and the marginalized. He left us with a remarkable legacy filled with compassion, moral clarity, radical hope, and optimism. Paul will be forever missed. In Bill Gates’s words: “There will never be another Paul Farmer.” Read the full piece. 

3. Forbes: “Countering Failures Of Imagination: Lessons We Learnt From Paul Farmer”  

In this piece for Forbes, Dr. Madhukar Pai recounts lessons learned from Paul Farmer, including the lessons of health care as a human right, accompaniment, and equity as central to global health. Pai recounts Paul's teachings to resist “failures of imagination” and move toward radical futures in solidarity with the poor. Read the full piece. 

4. The Wall Street Journal: “Expanding Global Access to COVID-19 Vaccines” 

In March, The Wall Street Journal hosted Sheila Davis and Tulio de Oliveira, director of the Centre for Epidemic Response and Innovation at Stellenbosch University in South Africa, for a discussion about global vaccine distribution and what should be done to face the next pandemic. Watch the video.

5. International Women’s Day: #BreakTheBias 

For International Women’s Day, PIH hosted a panel composed of Dr. Joia Mukherjee, chief medical officer at PIH, Dr. Cindy Duke, founder and director of Nevada Fertility Institute, and Edward Wageni, global head of HeforShe. The conversation centered around the importance of dismantling sexism and gender discrimination in health care and defended gender equity as an integral part of global health equity. Winston Duke, actor, producer, philanthropist, and PIH’s first global ambassador, served as the moderator. Watch the event.

6. NEJM: “Misusing Public Health as a Pretext to End Asylum—Title 42” 

In March 2020, President Donald Trump’s administration invoked Title 42, an obscure public health law, to use the COVID-19 pandemic as a pretext to deny asylum seekers at the United States border their right to protection. President Joe Biden’s administration, unfortunately, extended the order despite its devastating impact on vulnerable migrants, including those fleeing violence in Haiti only to face more mistreatment at the U.S. border. 

PIH leaders, namely Joia Mukherjee and Loune Viaud, contributed to a piece in the New England Journal of Medicine denouncing this decision and showing that there was no evidence that singling out asylum seekers contributed to stopping the spread of COVID-19. Read the full piece. 

7. The New York Times: “This Psychiatric Hospital Used to Chain Patients. Now It Treats Them.” 

In April, The New York Times covered PIH’s work over four years to renovate Sierra Leone’s only psychiatric teaching hospital, which is the oldest in sub-Saharan Africa. Renovations included a laboratory, an occupational therapy center, a soccer field, and a playground for the children’s clinic. New medications stock previously empty pharmacy shelves. Medical students also now conduct rounds in the now vibrant hospital, which serves as evidence of what is possible in Sierra Leone and across the Global South. Read the full piece. 

8. The Washington Post: “Where Pregnancy is a Deadly Gamble”  

Sierra Leone is one of the most dangerous countries on Earth to give birth. Its pregnancy-related mortality rate is surpassed only by Chad and South Sudan. The Washington Post released a story in May about PIH’s successful efforts in helping tackle that issue at Koidu Government Hospital in Sierra Leone. Read the full story.  

9. Pandemic Burnout: Impact on Nursing & Midwifery  

Nurses account for 60% of the global health workforce, forming the backbone of the global health system. The same holds true at PIH, where 54% of clinical staff are nurses. They have been on the frontlines of the COVID-19 response for more than two years. But that work has often come at the expense of their own mental and physical health.

During Nurses Week in May, PIH partnered with act.tv to bring together an impressive panel of nurse influencers to talk about the urgency of the global nursing shortage and the widespread burnout caused by the pandemic. Watch the event. 

10. Devex: “The Legacy of Dr. Paul Farmer Takes Shape in Congress”

In September, a new coalition in the U.S. House of Representatives, led by Reps. Jan Schakowsky, Barbara Lee, and Raul Ruiz, announced the Paul Farmer Memorial Resolution—among the most ambitious health legislation ever introduced in Congress. The resolution, presented as a “21st century global solidarity strategy,” asks the U.S. government to increase its global health aid to $125 billion, focusing on helping low-income countries build national health systems and empowering local partners. Read about the resolution. 

11. PIH Announces Winston Duke As First Global Ambassador

In November, PIH announced Winston Duke as the organization’s first global ambassador. Alongside his acting career, Duke has been a longtime philanthropist, humanitarian, and gender equity activist. The Black Panther star will represent the organization and join PIH in the fight for global health equity. In the spring, Duke traveled to Rwanda and saw first-hand how Inshuti Mu Buzima, as PIH is known there, is fighting injustice by providing quality health care across the country. Learn more. 

12. U.S. News and World Report: “Opinion: Enlist Community Health Workers to Help Patients Beyond the Exam Room”  

In December, Sheila Davis penned an op-ed for U.S News and World Report on how to improve health equity in the United States. In the article, she emphasized how PIH’s model, which focuses on addressing the basic needs of patients beyond medical care—such as food, housing, and transportation—has helped “dismantle health inequities for nearly four decades, reaching 12 million people with primary and specialized care and support across 12 countries.” Read the full piece. 

The maternal mortality rate is alarming in Sierra Leone, where 1 in 20 women face a lifetime risk of dying in pregnancy or childbirth. The mortality rate of infants and children under 5 are also among the highest globally: 122 deaths per 1,000 live births.

Many of these deaths are completely preventable when the right care is available. No woman should die from obstructed labor or a postpartum hemorrhage, nor should a child from diarrhea, pneumonia, or malaria.

In response to this injustice, Sierra Leone’s Ministry of Health and Sanitation (MOHS) is collaborating with Partners In Health (PIH) in the delivery of a pivotal project, the Quality Essential Health Services and Systems Support Project (QEHSSSP), which aims to improve care available at community health centers in rural districts so that patients, regardless of where they go, will receive the services they need—and deserve.

A partnership between the Government of Sierra Leone and PIH and funded by the World Bank, QEHSSSP is modeled after improvements made over the past several years at PIH-supported Wellbody Clinic and other facilities in Kono District. Patients have noticed the difference in quality of care, and each facility is now bustling with activity.

PIH leaders see huge potential in multiplying that impact more broadly.

“We should all see [this project] as a catalyst in changing and strengthening the health care system in Sierra Leone,” says Dr. Bailor Barrie, executive director of PIH Sierra Leone.

Project Goals

In December 2021, the World Bank approved a significant grant to support QEHSSSP, which will have a deep impact on maternal and child health services for 2 million people in Sierra Leone, a country of more than 8 million. The project focuses on 14 health facilities in five districts—Kailahun in the East, Bonthe in the South, Western Rural in the West, and Falaba and Tonkolili in the North—where the government of Sierra Leone will build resilient, efficient, and equitable health systems, with support from PIH. More specifically, the project aims to increase facility-based deliveries, access to basic nutrition services, and the number of pregnant women who receive a community health worker visit.

“This project will help very seriously to reduce maternal deaths,” says Michael Hallie Kendor, chiefdom speaker of Kissi Tongi in Kailahun District.

Key to success will be ensuring that each facility is equipped with essential health systems inputs. At PIH, we think of these investments as the five S’s:

• Staff: well-trained, qualified employees—such as nurses, midwives, community health workers, lab technicians, and more—in sufficient quantity to respond to patients’ needs
• Stuff: medication, diagnostic tools, medical equipment, furniture, and other resources to deliver services
• Space: safe and dignified facilities with the capacity to serve the community’s needs
• Systems: leadership and governance, information, and financial management systems for timely decision-making
• Social Support: meeting patients’ needs beyond medical care, including nutrition and social support

Improving Systems, Facilities 

PIH has decades of experience in designing and delivering primary health care with government partners. In Sierra Leone, leaders see this as a hub-and-spoke model reflected in the work across Kono District, at one point a district with among the poorest health care options, having been at the center of the years-long civil war. There, PIH supports Koidu Government Hospital (KGH), which is the main district hospital for specialized care, where patients access everything from emergency services and surgeries to pediatric and chronic disease care.  

At nearby Wellbody Clinic, a model primary care facility, patients access a variety of essential health services, such as prenatal and family planning appointments, malaria consultations, and malnutrition care. Complex cases, such as C-sections, are referred to the “hub” of KGH. Wellbody also serves as its own hub to which community health workers refer and accompany their neighbors from surrounding communities, and smaller “spoke” facilities. This continuous web of care flows back and forth, between hub and spoke, as patients’ needs are assessed, triaged, and met from community, to clinic, to hospital. 

The model, introduced in 2014 when PIH began working in Sierra Leone, has proved to be successful. There is an increased flow of patients and from 2018-2021, there were about 55% more facility-based deliveries, 116% more lifesaving C-sections, and 44% more antenatal care visits across all PIH-supported facilities in the country. Most importantly, there has been a significant decline in maternal and infant mortality. 

This success was recognized by the Ministry of Health and Sanitation (MOHS), which is why a hub-and-spoke model was prioritized for a new World Bank project that will support the ministry in creating new hubs across five districts. As with Wellbody Clinic in Kono District, to support MOHS, PIH will work to build health systems within the Jojoima, Bandajuma, and Buedu facilities in Kailahun District. In the other four districts, PIH will serve as an advisor to the MOHS, in an effort to replicate the hub-and-spoke model across 11 of the districts’ rural health centers.

Overcoming Challenges

While each facility and location are unique, they uniformly need immediate infrastructure improvements. Nearly all of the 14 health facilities struggle with electricity, making it difficult to provide services at night or power lifesaving equipment. Some lack access to water, leaving them with sanitation systems that, among other things, make sterilizing instruments challenging. 

“We are not able to handle some emergencies right now. We lack the necessary infrastructure,” says Ibrahim Allieu, a community health officer at Bandajuma Community Health Center in Kailahun District. “The well-being of our people in the community has been seriously impacted by this.”

Facilities lack well-stocked pharmacies, which leads to an inadequate drug supply and sometimes forces patients to buy questionable medication from outside vendors—or go without. Well-trained and sufficient staff is also in short supply. All of these and many other challenges have made it nearly impossible to deliver high-quality health services across the facilities.

Marian Sanjah, a midwife, juggles this reality every day at Jojoima Community Health Center in Kailahun District. “Our labor room is out of space and we struggle to get water at the facility,” Sanjah says. “Even though we have a solar-powered generator, we struggle with electricity. We experience frequent power cuts.”

“We use our phone lights or rechargeable flashlights to deliver [babies] at night,” she adds. “We are constrained and find it difficult to do our work. Delivering shouldn’t be done in the dark.”

Early Signs of Progress

PIH Sierra Leone staff and government partners have assessed all public clinics across the five districts to determine short- and long-term needs. Soon, repairs and construction will begin, medications will arrive to fill bare pharmacy shelves, and staff will receive training on new diagnostic testing that will ultimately improve the quality and variety of care available to patients in rural communities. 

The work will be similar to what has already taken place at the health center in Gandorhun in Kono District. The remote facility shines with a fresh coat of blue and white paint. Water and electricity are now available 24 hours a day. And lab and pharmacy staff prepare their renovated and stocked spaces for what will inevitably be a steady flow of patients.

Several hours further along a rutted dirt road, a large, modern facility rises within a walled compound up the hill from the Jojoima Community Health Center. The facility, built by the MOHS with support from the World Bank, will serve as a referral center for the surrounding region and specialize in maternal and newborn care, but will also be home to pediatric care and other essential health services. 

Touring the grounds on a recent September afternoon, Barrie envisions a future maternal waiting home at the site of the current health center and points to where the pharmacy, laboratory, kitchen, and laundry facilities will be, ideally, with a March 2023 opening. PIH is helping partners develop operational plans for the impressive facility, learning from work done in Kono District.

Meanwhile, back at Bandajuma Community Health Center, Allieu surveys the humble facility where he and other clinicians do what they can to deliver care without access to running water, electricity, and sufficient stock of essential medications. He has seen the work MOHS and PIH Sierra Leone have done together in neighboring communities, and he has hope.

“I believe with this intervention, some of these challenges will be addressed,” says Barrie.

When a 26-year-old man arrived at the hospital dripping in blood and holding nearly all of his intestines, Dr. Sterman Toussaint was optimistic.

“I told him to calm down and that everything would be okay,” says Toussaint, a surgeon and the director of clinical services at Partners In Health (PIH) Liberia.

The man suffered a stab wound. He was anxious and fearful of death because he couldn’t afford care. Unbeknownst to him, he didn’t need to be concerned: surgery is free for patients at PIH-supported J.J. Dossen Memorial Hospital.

His procedure went well and six days later he was sent home.

“In this case, how could surgery be a luxury? He didn’t stab himself. He had the right to live and that’s what he’s continuing to do,” says Toussaint.

Essential Care

Surgery is a necessity, not a luxury. It’s an investment, not a cost. Yet it often gets overlooked in low- and middle-income countries. Surgery is the “neglected stepchild of global public health,” PIH co-founders Drs. Paul Farmer and Jim Yong Kim wrote in a published paper more than a decade ago. At the time, basic surgical care wasn’t available in southeast Liberia.

If a person suffered an accidental injury, such as a stab wound or broken bone, or a mother needed a C-section, they had to travel hundreds of miles to the nearest clinic with a surgeon. People would often die during the costly journey that took several days due to poor roads. Staff at PIH Liberia vividly remember those days.

Specifically, they recall a motorbike rider who arrived at the hospital with a protruding bone and obvious signs of infection. Without a surgical team in place there was not much the staff could do for him, so they referred him to a clinic about ten hours away. The van got stuck and the patient died before reaching the hospital.

“Today, the story is different,” says Dr. Gerard Ekwen, a general surgeon who has worked at PIH Liberia since 2018.

Since then, Ekwen and his colleagues have completed more than 2,000 lifesaving surgeries at J.J. Dossen Memorial Hospital. Without those services, many people would likely have died from preventable health issues.

Steady Progress

Surgical cases have been on the rise since 2018 when Ekwen, nurse anesthetists, and an obstetrician were hired. Between July 2021 and June 2022, the comprehensive team completed 608 general surgeries, 290 C-sections, and 28 gynecological surgeries.

The quality of care is improving too.

There has been a steady increase in the use of general anesthesia in major surgical cases and a decrease in less safe methods such as the use of laryngeal masks and endotracheal intubation, both of which are inserted down a patient’s windpipe. This is because of well-trained staff—one of the five key elements of strong health systems. Highly skilled nurse anesthetists at PIH-supported facilities have the necessary skills to intubate and administer general anesthesia drugs and safely manage patients during surgery.

“Surgery is an integral, non-negotiable component of primary care in the developing world,” says Dr. Maxo Luma, executive director of PIH Liberia. “When surgery is well integrated into primary care, we save lives.”

As the team continues to grow, they’re simultaneously training the next generation of health care providers who specialize in surgery. Every year, residents and interns from Monrovia, the country’s capital, shadow surgeons at J.J. Dossen Memorial Hospital. They learn basic surgical skills and how to diagnose and treat patients with a range of conditions. Such training is a priority for PIH Liberia and PIH at large to build resilient and sustainable health systems.

Additional training is offered through the Global Action to Improve Nurse Midwifery and Care (GAIN) program, a cross-site mentoring initiative designed to train and empower nurses and midwives in Malawi, Liberia, and Sierra Leone. Thirty fellows have graduated from the program since its inception in Liberia in November 2020. The latest cohort of 14 fellows started their training in October. The academic and on-the-job training provided by GAIN plays a key role in establishing career pathways for nurses.

“As Partners In Health, we are committed and we are here to stay,” says Dr. Sarah Anyango, an obstetrician and PIH Liberia’s deputy director of clinical services. “We are committed to making sure we are giving care that is equitable, accessible, and affordable to the people of Maryland County.”

In the rural community of Reforma, 100 teens gathered to take photos, make collages, and paint a mural. But the lesson was about more than art.

The activities were part of a three-day workshop on sexual and reproductive rights hosted by Partners In Health, known locally as Compañeros En Salud. The workshop, held in September, is one of many ways that Compañeros En Salud helps young people in Chiapas, Mexico learn about their health and rights.

Compañeros En Salud has worked in Mexico since 2011, where it has partnered with the Ministry of Health to strengthen the public health system and improve patients’ access to care. Compañeros En Salud supports a hospital in the city of Jaltenango and clinics in 10 rural communities, along with a workforce that includes doctors, nurses, midwives, and community health workers.

Sexual and reproductive health have been crucial to that work. In Chiapas, Mexico’s southernmost state, the population is young, with the median age 24 years old, and rates of teen pregnancy and sexually transmitted infections are high, due to poverty and systemic barriers. Many patients seeking this care from Compañeros En Salud are teens and young adults.

After meeting with local leaders in Reforma, one of the communities where it works, Compañeros En Salud identified the need for sexual and reproductive health education. That inspired the team to organize the workshop.

Designed for students ages 12 to 15, the workshop used art to explore sexual and reproductive health, with topics ranging from consent to community. Lessons were divided into three units: “Our Life Plan,” “Our Community,” and “Our Body.”

In "Our Life Plan," students envisioned their dreams and goals in life, while also learning about the importance of family planning and the consequences of an unplanned pregnancy. Those dreams ranged from owning a home and planting coffee to becoming a hairstylist in New York.

In "Our Community," students tried their hand at photography and theater. They took photos that represented what community meant to them and acted out scenes that explored concepts like bodily autonomy and contraceptives.

In "Our Body," the lesson focused on consent, helping students connect with their bodies and notice how and when they felt comfortable, uncomfortable, safe, or in danger. This unit included role-playing exercises to practice various situations in which they might feel pressured to say yes, but had the right to say no.

Students came away from the experience with a greater understanding of their rights and resources, as well as a deeper sense of community—captured by a vibrant mural in a local park that served as the workshop’s final project.

"This workshop was very useful for me,” says Uver, 13, a student from Reforma. “I can plan what I want in the future, thinking about the repercussions of each decision I make, and thus achieve my goals.”

Students weren’t the only ones taking notes.

“When we think of strategies to engage with rural communities, there must be a decolonization of knowledge,” says Marina Luria, content manager at Compañeros En Salud, who helped organize the workshop. “We don't have all the answers and we have a lot to learn from the communities where we work. This workshop was a learning space for us, too."

It started with thirst.

Then came cramps. Then, hallucinations. That’s when Meysi Mendoza knew something was wrong.

The 53-year-old resident of Carabayllo, a district in northern Lima, had been feeling fine until then, selling fish, plantains, and aguaje, a fruit found in Peru’s Amazon rainforests, at the market as usual. But the sudden wave of symptoms alarmed her.

Mendoza, who has four adult children but lives alone, decided to seek help. She’d seen a poster at the local bodega about a free health campaign organized by Socios En Salud, as Partners In Health is known in Peru. It was scheduled for June.

There, at the clinic, she received a spate of tests and some unsettling news: she had diabetes.

Diabetes is a chronic health condition that affects 537 million people worldwide. Of the people with diabetes, almost 80% live in low- and middle-income countries, due to poverty and systemic barriers that prevent patients from accessing testing, treatment, and care.

For nearly 30 years, Socios En Salud has partnered with the Ministry of Health and local communities in Carabayllo and beyond to strengthen the public health system, along with improving access to testing, treatment, and care, free of charge. Since 2009, that work has included the Casas de la Salud program, which helps patients access treatment for diabetes and other chronic diseases, such as hypertension.

Casas de la Salud has connected hundreds of patients with care.

From October 2021 to June 2022, Casas de la Salud conducted follow-ups with 573 patients through home visits and virtual check-ins and accompanied 103 patients to medical appointments, helping them stay on track with their treatment plans. Sixty percent of the patients were women with Type 2 diabetes.

Mendoza was one of those patients.

After accessing screening and a diagnosis through Socios En Salud, she was connected with the Casas de la Salud program—and care.

That care included check-ins with a community health worker, one of 262 community members hired and trained by Socios En Salud to deliver medicine to patients’ homes, check in with them, and help them schedule and attend their medical appointments.

It also included a consultation with a nutritionist, who helped Mendoza review and modify her diet. Diabetes ran in her family, and she was also overweight, unable to maintain a healthy diet due to her demanding job. With the support of a nutritionist, she made plans to cut down on fat, flour, and sugar as much as possible.

“At the beginning, it was very difficult to adapt these new changes in my diet, because I was very used to eating seasoned and sugary foods,” she says. “However, I knew it was for my own good, so I followed all the doctor’s instructions.”

Now, months later, Mendoza is on track with her treatment plan. She takes three pills per day and attends monthly appointments at Hospital de Apoyo in Carabayllo, where her vital signs, blood glucose, and hemoglobin are monitored.

The community health worker assigned to her case, Elizabeth Anchante, is there to support her every step of the way, along with Socios En Salud’s team.

“I feel very grateful for the support,” says Mendoza. “The attention Socios En Salud provides is frequent. I know I can go to them quickly if I have any questions.”

As the latest cholera outbreak in Haiti continues, its impact is clear: children under 5 have been most affected. 

As of December 6, the Haitian Ministry of Public Health and Population (MSPP) reported 13,586 suspected cases of cholera, 11,670 hospitalizations, and 285 fatalities. The unofficial toll is likely even higher.  

Early on, clinicians noted that children were hardest hit by the disease, which causes diarrhea and vomiting and, when severe, can lead to fatal dehydration within 24 hours.  

Widespread Malnutrition 

“We were asking ourselves this question: ‘Why are children the main victims of cholera?’” said Dr. Jean Joel Manasse, an internal medicine physician and head of the cholera treatment unit at Hôpital Universitaire de Mirebalais (HUM), which is supported by PIH’s sister organization in Haiti, Zanmi Lasante, and built in partnership with the MSPP. Now, even as the percentage of adults with cholera rises, children remain the majority of cases, about 65%, Manasse said.    

One reason is widespread malnutrition. “A significant proportion of children with cholera also have associated malnutrition,” which, Manasse explained, tends to leave young immune systems more vulnerable to disease. “Those [cholera patients] with longer hospital stays face a risk of complications such as acute lung edema, infection, limb edema,” and other problems associated with severe malnutrition, he added. 

Malnutrition is on the rise in Haiti. According to The New York Times, “the United Nations reported [in October] that for the first time ever, hunger, which has long haunted Haiti, had reached “catastrophic” levels in the Cité Soleil neighborhood” of Port-au-Prince, among the most impoverished areas of the capital city. That designation is the most extreme level of hunger, which has left thousands facing famine-like conditions, the  article stated, noting that some residents have resorted to drinking rainwater and making meals out of boiled leaves.  

At HUM, physicians are initiating malnutrition treatment right at the cholera treatment centers, Manasse said, and then ensuring that children are referred to pediatricians and enrolled in the hospital’s nutrition program. 

Dire Working Conditions 

Staff continue to treat patients despite a country plagued by gang-related violence, kidnappings, rampant inflation, and ongoing shortages of fuel and other necessities. 

At Zanmi Lasante, Executive Director Marc Julmisse said the teams at HUM and five other ZL-supported clinics continue to work around the clock to provide cholera care, despite daily challenges.  

“On September 12, our country came to a standstill,” said Julmisse, speaking about conditions in Haiti as part of a PIH global health webinar in November. “We had been dealing for years with kidnappings, gang violence, roadblocks, but this is unprecedented. We haven’t seen it before.”  

Julmisse talked about the risks staff face simply getting to and from work, and acquiring much-needed fuel which, at its worst, was being sold for $20 a gallon due to countrywide shortages. “We had to make some tough decisions just to keep the doors open,” she said.   

But the doors have remained open, she added, as cholera cases keep rising.  

The first official case was on October 2. Within two weeks that number jumped to 66 cases. Now, case reports from the Ministry of Public Health and Population tick upwards daily.  

At HUM, the 60 beds for cholera patients quickly filled up; there were 200 patients being treated as of December 7 with a a total of about 1,000 cholera patients have been cared for and treated at HUM, a state-of-the-art teaching hospital built following Haiti’s devastating 2010 earthquake.  

Julmisse said the ZL team is actively working on opening new cholera treatment sites around the region and collaborating with medical and health care organizations throughout Haiti to strategize on how best to treat patients and save lives. 

This cooperation, she said, is critical: “It’s like, ‘What do you have, what do we have, can we share?’” she said. “We have formed a community of proactive groups to better understand what’s going on, each advocating for each other.”   

For instance, she said, it became clear that the community of Lascahobas was facing an increase in cases, but many patients living in remote, rural locations could not make the trek to clinics for care. This information was relayed to community health workers, and plans are now underway to get teams to that area to help residents who are sick.  

Recently, Airlink, an organization that works with partners, including Zanmi Lasante, to deliver crucial supplies during humanitarian crises, has established an “airbridge” to get water, sanitation, and hygiene supplies to Haiti to mitigate the outbreak.  

“We are in a dire situation,” Julmisse said. “But we have an amazing team.” 

Dr. Christophe Millien, medical director at HUM, said several new general practitioners and a pediatrician have been hired to help manage the cases. But critical needs for additional cholera treatment centers remain, notably: tents, beds, oral rehydration salts, IV and hygiene supplies, and more.  

Importantly, PIH and ZL, alongside government partners, are anticipating oral cholera vaccine to arrive in Haiti on December 12, with a coordinated vaccination campaign launching two days later, officials said. 

Cholera’s History in Haiti 

Cholera had not been detected in Haiti until after the 2010 earthquake, when it was inadvertently introduced by United Nations security forces, sickening 820,000 people and causing almost 9,800 deaths. After multiple, successful mass vaccination campaigns led by PIH and others, and a decision by the World Health Organization to create a cholera vaccine stockpile, cholera was declared eliminated from Haiti in February 2022.  

However, according to a recent analysis in The New England Journal of Medicine, reemergence of the disease was caused, at least in part, “by a descendant of the [cholera] strain that caused the 2010 epidemic.” 

The authors of the NEJM piece, including those affiliated with PIH, suggest several explanations: that the original strain persisted undiagnosed in the population  and recurred “in the context of waning population immunity coupled with a crisis in lack of clean water and sanitation;” that the strain persisted in environmental reservoirs; or that the current strain could have been reintroduced in Haiti from a nearby country. 

In any case, the authors conclude: “These findings, along with the resurgence of cholera in several parts of the world despite available tools to fight it, suggest that cholera control and prevention efforts must be redoubled.” 

In February 2022, Partners In Health’s (PIH) Co-founder and Chief Strategist Dr. Paul Farmer unexpectedly passed away. PIHers and individuals around the world mourned his loss and reflected on his commitment to delivering justice through health care, a movement he and others started more than 30 years ago that continues to save millions of lives today. Unsurprisingly, many of our most-read stories and social posts discussed Paul’s legacy. 

PIH supporters were also curious to learn more about our health care facilities and how we respond to emergencies, including natural disasters and cholera outbreaks in Haiti and Malawi. That curiosity extended beyond clinical work and to our advocacy efforts. From gender equity to systemic change, supporters wanted to know how to advance health care as a human right.

Below are our most-read stories, social posts, and videos published in 2022.

Dr. Paul Farmer

1. Remembering Dr. Paul Farmer

Paul passed away from an acute cardiac event on February 21. He is survived by his wife, Didi Bertrand, and their three children. Read more.

2. Watch: Dr. Paul Farmer's Memorial Service

The two-hour memorial service took place at Trinity Church in Copley Square in Boston, Mass., where Paul began his medical school journey and co-founded PIH. More than 600 people gathered that day to mourn and thousands more joined virtually, from Rwanda to Peru. View more.

3. Watch: Dr. Paul Farmer Tribute Video

PIH shared a tribute video with archival photos and videos of Paul during the March 12 memorial service at Trinity Church in Boston. Watch the video.

4. Photo Essay: Dr. Paul Farmer's Journey with Partners In Health

A glimpse of Paul’s more than 30 years treating patients, educating clinicians, and changing global health policy. Read more.

5. 5 Quotes from Dr. Paul Farmer that Inspire Us

These five quotes are a sample of the wealth of knowledge and insights Paul shared with all of us, captured in books, speeches, and conversations throughout his life. Read more.

Global Work

6. With Instability in Haiti, Doors Remain Open at PIH Facilities

Not only is Zanmi Lasante (ZL), PIH’s sister organization in Haiti, providing essential services in the midst of a crisis, it also continues to strengthen health systems overall through its medical training programs. The internationally accredited Hôpital Universitaire de Mirebalais’s  residency programs in 11 specialties graduate more clinicians every year, the majority of whom remain in Haiti to work. Read more.

7. Watch: Cange Declaration (Bending The Arc Excerpt)

In this clip from the documentary Bending the Arc, PIH Co-founder Dr. Paul Farmer reacts to archival footage of Haitians living with HIV--among them his former patients--reading aloud the Cange Declaration, a manifesto they wrote imploring world leaders to provide equitable access to antiretroviral treatment. Watch the video.

8. A New Cholera Outbreak Emerges in Haiti

ZL has been distributing food and hygiene supplies to staff and trying to procure fuel to keep medical facilities running. The team is also working with international partners to rapidly distribute essential supplies to respond to cholera, which reemerged in Haiti in October. To date, not one ZL facility has closed or been forced to stop caring for patients throughout the region as the number of people affected continues to climb. Read more.

9. Cyclone Rips Through Malawi Inflicting Massive Damage on Clinics, Homes

Abwenzi Pa Za Umoyo (APZU), as PIH is known in Malawi, reached at least 2,800 people affected by a powerful cyclone that swept through the country’s south in January and delivered emergency packages across Neno District, where APZU focuses its work. Read more.

10. Cholera Outbreak Spreads Through Southern Malawi

Following an outbreak of cholera in March, APZU continues to fill medical and other gaps, for instance, by helping to procure more treatment and test kits and mobilizing a cholera vaccination plan. This is not new for PIH: successful cholera vaccination campaigns were launched previously in Sierra Leone and Haiti. Read more.

11. Watch: Kayima Community Health Center

Take a look inside Kayima Community Health Center, a clinic serving one of the largest communities in rural Kono District, Sierra Leone. The center is among a handful of PIH-supported facilities in the eastern region that are undergoing renovation and quality improvement projects to boost patient care, especially for mothers and children. Watch the video.

12. The Promise of Butaro District Hospital: Key Facility Meets Growing Demand, Need for Expansion

PIH and the Rwandan government broke ground on the next phase of growth for PIH-supported Butaro District Hospital. The ambitious, multi-year construction project is set to expand the hospital, located in northern Burera District, from 150 to 240 beds and further establish it as a leading medical institution and teaching hospital in the region, linked to the neighboring University of Global Health Equity. The facility provides thousands of people access to primary care and specialized services, such as oncology. Watch the video.

United States

13. Repeal of Roe v. Wade

In June, the U.S. Supreme Court overturned Roe v. Wade. PIH stands firmly behind women’s autonomy as a core principle of health equity. Read more.

14. Watch: PIH Chief Medical Officer Delivers Commencement Speech

Dr. Joia Mukherjee delivered an inspiring commencement address at the University of Michigan Medical School. She talked to future doctors about her personal experiences, her hope for the future, and the work PIH has done. Watch the video.

Advocacy

15. International Day of the Girl

PIH is proud to join other organizations around the world to celebrate International Day of the Girl in October. This year's theme —"Our time is now—our rights, our future"—reminds us that gender equity is ongoing work. Read artist, producer, activist, and PIH supporter Rosario Dawson’s statement.

16. Tipping the Scales of Justice, Presented by PIH

Moderated by PIH Co-founder Ophelia Dahl, a panel of powerful activists discuss modern day activism, the role of social media, and the importance of going beyond social platforms to create systemic change. Watch the video.

In November, PIH-US was invited to represent the Chicagoland Vaccine Partnership at the White House’s Summit on COVID-19 Equity and What Works Showcase.  

The event, which convened over 30 community-based organizations and community, government, and philanthropic leaders from across the country, highlighted bright spots from hyper-local efforts to alleviate the disproportionate impact of the COVID-19 pandemic on hard-hit populations.  

As part of the Chicagoland Vaccine Partnership, a consortium of community, philanthropic, government, and health care organizations, PIH-US helped to direct more than $3 million in grants to 100+ community-based organizations to design their own COVID-19 outreach and vaccine access solutions. These grants were used to help increase access to vaccine education, decrease barriers to vaccination, increase vaccine uptake, and coordinate broader COVID-19 relief efforts. In addition to distributing small grants, the Chicagoland Vaccine Partnership implemented several strategies to support equitable vaccine efforts including: partnering with Malcolm X College and the Chicago Department of Public Health to offer a free online training to equip community members to speak to their neighbors about vaccination; creating a scheduling tool to support vaccination registration; establishing a virtual learning community that provided a space for community members to problem solve, share personal stories, and exchange the latest resources; and launching a Speakers Bureau that connected area doctors, nurses, and other providers with interested community groups to share accurate, accessible, up-to-date information about COVID-19 and vaccines. 

Community-led efforts like those highlighted at the White House Summit are critical for not just closing gaps in vaccine inequity, but addressing the long-standing health injustices that underpinned barriers to COVID-19 vaccination. 

Below, we share photos from the event.  

In early 2020, as millions worldwide were grappling with the onset of the pandemic, Cruz Antonio Sifuentes was weathering another storm: a diagnosis with HIV.

The 35-year-old resident of Los Olivos, an impoverished community in Lima, knew little about the disease. But he feared the worst.

“The first thing I thought was that I was going to die,” he says.

He had felt sick for weeks, waking up in the middle of the night with cold sweats and battling so much fatigue that he could only walk a few steps before needing rest.

Despite his worsening symptoms, he worried that he wouldn’t have the money to see a doctor. As the pandemic took hold and cities went into lockdown, he had lost his job as a security guard; it was unclear when his next paycheck would come. And there were only so many jobs he could do in Lima as a migrant from Venezuela.

As he got sicker and his money dwindled, he heard about a free mobile health clinic in his community, geared toward migrants. The clinic was run by Socios En Salud, as Partners In Health is known in Peru.

Sifuentes hadn’t heard of Socios En Salud, but knew he needed help and decided to go. There, at the mobile clinic, he was able to access HIV testing, free of charge.

The result was positive and Sifuentes, devastated.

“That day was horrible,” he recalls. “The truth is that I don’t even know how I had the strength to make it.”

Lifelines

HIV affects 38 million people worldwide. In Peru, 91,000 live with the disease, according to the Ministry of Health. Low- and middle-income countries are disproportionately affected by the virus due to longstanding injustices in global health, including lack of access to treatment.

Socios En Salud has worked in Peru since the 1990s to expand access to treatment and care, first with multidrug-resistant tuberculosis and then with HIV and a host of other health conditions. That work, carried out in partnership with the Ministry of Health and local communities, has saved thousands of lives. This year, Socios En Salud screened 1,500 people for HIV and connected 92% with antiretroviral therapy.

Through Socios En Salud’s support, Sifuentes was able to access free HIV treatment just days after his diagnosis, along with support from a community health worker—one of 262 locals hired and trained by Socios En Salud to help patients stay on track with their treatment and navigate the health system.

HIV treatment and care weren’t the only lifelines for Sifuentes: he was also able to access mental health care.

HIV is treatable, and access to antiretroviral therapies (ART) has dramatically improved over the decades, with 75% global ART coverage. But despite this progress, testing and treatment remains difficult to access in impoverished places and the disease is still widely stigmatized and misunderstood.

The AIDS epidemic, which began in the United States in the 1980s, was blamed on gay men, fueling violence and discrimination against the LGBTQ+ community and leading to widespread stigma around the disease, along with the enduring misconception that HIV leads to death.

Such stigma makes mental health support especially crucial for people living with HIV. As part of its work in HIV and other clinical areas, Socios En Salud provides mental health care to patients, free of charge.

'I see this as a rebirth’

At first, Sifuentes told no one about the diagnosis.

Through Socios En Salud’s mental health program, he was able to access therapy and a support group to process his complex feelings, eventually making the decision to share the news of his diagnosis with the people he trusted most—his best friend and his sister. The disclosure, while difficult, helped him feel less alone and opened up more sources of support in his life.

His physical health was showing signs of improvement, too.

As he took his medication at 10:30 each night, his energy began to return. Day by day, he felt stronger and more in control. His symptoms started to fade.

Now, two years later, Sifuentes says his life has completely changed.

“I no longer feel tired or run out of energy,” he says. “I can do all my activities all day and without feeling sad or depressed.”

He continues to take his medication. He is working again. And he is using his story and first-hand experience to help others, spreading the word about HIV care and countering stigma and misinformation. For those who are navigating the unknowns before and after an HIV diagnosis, he has a simple yet powerful message: healing is possible.

“I was afraid and scared of having the disease. At the same time, I felt relieved…that I was not alone,” he says. “Now, I see this as a rebirth.”

Cholera outbreaks in Haiti and around the world are worsening, triggered by droughts, floods, war, and political instability that have forced vulnerable people to live amidst unsanitary conditions. At Zanmi Lasante (ZL), PIH’s sister organization in Haiti, doctors and medical staff are currently caring for more than 300 cholera patients at six clinics and hospitals in central Haiti; but more than 800 total have already been treated at ZL’s teaching hospital, Hôpital Universitaire de Mirebalais.  

The Haitian Ministry of Public Health and Population reported 11,953 suspected cases of cholera, 10,247 hospitalizations, and 227 fatalities as of November 28.

Children under 5 have been most affected; one reason is that malnutrition, which afflicts about 1 in 5 children in Haiti, makes young immune systems more vulnerable to disease. Cholera causes such severe vomiting and diarrhea that—if left untreated—a patient can die from dehydration within 24 hours.

Haitians never experienced cholera before 2010. That year, a new group of United Nations peacekeepers arrived in the country from Nepal, which had suffered a spike in cholera cases, and set up operations in a long-established base near Mirebalais with poor plumbing. Contaminated sewage leaked into the Artibonite River, a major water source for all Haitians, leading to a massive national cholera outbreak that lasted many years and killed more than 9,000.

PIH was among the first responders to that 2010 outbreak, ultimately treating more than 180,000 people in Haiti.  In 2012, PIH and its partners launched mass cholera vaccination campaigns in Haiti, reaching more than 45,000 people. That successful early effort led the World Health Organization to call for the establishment of a global stockpile of cholera vaccine. Additional mass vaccination campaigns, in 2016 and 2017, followed.

But the current surge in cholera globally has “so severely strained the supply of cholera vaccines that global health agencies are rationing doses,” according to The New York Times. 

We reached out to Garrett Wilkinson, PIH’s government relations and policy officer, who has been working on issues related to vaccine access for COVID, mpox (formerly monkeypox), cholera, and Ebola over the past few years, to better understand the status of the global cholera vaccine stockpile, why its supply is not meeting demand, who is most impacted, and what PIH is doing to make a difference.  

What is driving the current global shortage of cholera vaccines?

There’s limited funding to purchase cholera vaccines, and as a result there’s limited production. Most of the world's current cholera vaccine is manufactured by EuBiologics in South Korea. Around 15% of the world’s cholera vaccine is made by an Indian subsidiary of Sanofi (the company from which PIH directly purchased the original doses distributed in Haiti in 2012), but they’re leaving the market next year. EuBiologics is expanding manufacturing capacity and another manufacturer will be entering the market soon, but there will be a gap in availability of doses as these manufacturing shifts occur. 

Additionally, demand has grown with an increasing number of emergencies, such as the flooding crisis in Pakistan.  

Around 36 million doses are expected to be produced this year.

Wasn't the stockpile created to deal with such shortages? Why is it so depleted?

Like most global health programs, the size of the program is smaller than the burden of disease. We, as a global community, need to raise our aspirations, announce an intent to purchase millions more doses each year for the foreseeable future, and work with manufacturers to scale production to meet that demand. So, yes it’s about funding and supply and demand, but also a skewed global economy that doesn’t invest in preventing public health emergencies.

Who is most affected by the current vaccine shortage? Is the vaccine being rationed in countries experiencing cholera outbreaks?

Because cholera thrives in settings with limited clean water and sanitation infrastructure, those most impacted by the disease are the global poor and victims of natural disasters and war.

Right now, the cholera vaccine is being rationed to make up for supply constraints. It is usually given in a two-dose series, but as of mid-October, the International Coordinating Group (ICG), which was established in 1997 to coordinate the global distribution of vaccines to United Nations agencies including WHO, UNICEF, MSF, and the International Federation of Red Cross and Red Crescent Societies, have made the exceptional decision to recommend only administering one dose in order to stretch the limited supply.

One dose of the vaccine provides between six and 24 months of immunity, while the two-dose regimen delivered four weeks apart gives four years of protection. It’s urgently important that we scale production so we can maximize the benefit this vaccine can confer to people in need. 

What is PIH's involvement in this situation?

PIH has advocated for mass cholera vaccination campaigns for years, particularly in Haiti during times where other global health leaders disparaged cholera vaccination as not cost-effective. Because cholera can usually be treated with oral rehydration salts and antibiotics, some have argued that spending $1.50 per dose for millions of people is far more costly than merely treating the sick. This argument is misguided. First of all, people deserve not to be sickened with cholera in the first place. And secondly, vaccination can stop transmission and prevent an epidemic from spreading.

PIH is calling for increased cholera vaccine production. We’re speaking with our global partners about how we can raise sufficient funds to elicit increased production from existing or new manufacturers (this is sometimes called an Advance Market Commitment). The United States is a major investor in the United Nations system and ICG. U.S. global health funding is determined by Congress. Reaching out to your Congress member and raising this urgent concern to their attention can help.  

What is being done globally to fix this crisis?

Presently, this crisis is being addressed by dose rationing. This may be necessary to stretch limited supply in the short term, but it is an unacceptable strategy in the long term. While the primary cholera vaccine producer is increasing manufacturing, it’s not doing so by nearly enough. We need to see global partners step up with bold goals to administer millions more doses than we are now and to work with manufacturers to meet this demand.

The world has produced tens of billions of COVID-19 vaccine doses over the last two years. The technological challenge at hand with scaling cholera vaccine production is a mere fraction of what we just accomplished with COVID-19 vaccine production. We know it can be done. What is standing in our way is a lack of political will.

What about Haiti, specifically?

The Haitian Ministry of Public Health and Population and the prime minister have agreed to order cholera vaccine doses from the global stockpile. The total quantity of doses available and the arrival date in the country are still to be determined, but it could be in the next few weeks.

Learn More

Finding the best nonprofit to support requires some research. The organization’s mission should align with your personal values. It should tackle the complex issues you are passionate about. And it should have a proven record of impact.

So, how do you assess that?

Get to know them. Read what they write, listen to what they say, and—most importantly—watch what they do. Volunteer your time and attention to their work. Share what you have learned about them with others. And, when the time is right, support their work through donations.

At Partners In Health, we deeply value our supporters, especially those who attend our events, volunteer their time through grassroots advocacy, and donate to support the work we do all around the world.

Here are five reasons PIH has earned that support:

1. We Achieve Long-Term Impact

We measure our impacts over decades. PIH is not an emergency response organization, at least not in the traditional sense. Our global staff definitely respond to crises—both natural and manmade—but we do so while building stronger health systems for the long term.

We take this approach because those in need are our neighbors, friends, and family; 99% of PIH staff were born and raised in the country where they work.

We provide care and support for patients and their families. We learn from, mentor, train, and educate those working alongside us. We conduct research to discover best practices, then share those lessons learned with the larger world. And we use that evidence to influence national and global leaders, who can replicate and adapt our successful models of care in more countries around the world.

One key example of our unique model is our HIV work, which started in Haiti in the late 1990s and then spread around the world.

That is long-term, generational impact.

2. We Merge Social Justice with Medicine

PIH is a global health and social justice organization driven by a medical and moral mission to provide health care to those who need it most.

Our clinicians place patients at the center of all decision-making. Taking that perspective, we see that the right diagnosis and treatment plan is only part of a patient’s cure; we also need to address their social, emotional, and financial situation to effect lasting change.

When we look at this whole picture, we see the need to advocate for and with our patients, to fight injustice—in all its many forms—so that they will be able to enjoy their full right to health.

As our Co-founder Dr. Paul Farmer once said, and our supporters firmly believe: “The idea that some lives matter less is the root of all that is wrong with the world.” 

3. We Accompany Our Partners

PIH’s work is built on optimism, action, and accompaniment—doing whatever it takes, for as long as it takes, to ensure our patients’ right to health.

We accompany first and foremost our patients, whom we often refer to as “our bosses,” but we also accompany colleagues in ministries of health, public officials, partners, and our supporters as we learn from and with each other.

Only by keeping an open commitment to collaboration, we can aspire to solve problems caused by centuries of oppression and to find the hope needed to overcome seemingly insurmountable challenges.

Our community health workers embody accompaniment in every country where we work. They are recruited from their communities, trained and mentored, and serve as the living link between their neighbors, friends, and family and local health facilities. Their regular home visits forge a connection with patients and help guarantee successful outcomes.

4. We Disrupt the Status Quo

In the late 1990s, PIH leaders delivered a message that no one in the global health establishment wanted to hear: thousands of miles away, in Peru, people were dying of multidrug-resistant tuberculosis—a deadly infectious disease—and world leaders had turned their backs. With the right medication regimens and steady support from community health workers, our clinicians proved that patients could be cured at higher rates than previously thought possible.

It wasn’t the first time PIH had challenged the status quo. And it wouldn’t be the last.

Since 1987, PIH has been caring for some of the world’s most impoverished patients and speaking truth to power, because we firmly believe a better, more just world is possible. 

Our defiant optimism has changed global health policy and strengthened the movement for health equity worldwide.

5. Your Money Goes to Patients and Programs

We can proudly say 92% of the money PIH raises each year is funneled directly to support our global programs. Recognizing this effective use of funds, Charity Navigator awarded us its top four-star ranking as one of the nonprofits to which supporters can “give with confidence.”

Read our annual report to see what we accomplished, thanks to our supporters, last year.

Babies born prematurely or with complications in Kirehe, Rwanda now have a higher chance of survival.

Partners In Health recently opened a newly-renovated Neonatal Intensive Care Unit (NICU) at Kirehe District Hospital, in partnership with the Rwandan Ministry of Health. The NICU will provide lifesaving care for newborns in one of Rwanda’s busiest maternity wards.

“The newly renovated NICU will improve the quality of care, help staff to easily identify newborns who need immediate care, and will be a friendly, safe [environment] for the mothers, babies, and staff,” says Dr. Jean Claude Munyemana, the hospital’s director general.

Partners In Health, known locally as Inshuti Mu Buzima, has worked in Rwanda since 2005 and in Kirehe since 2006. Inshuti Mu Buzima partnered with the Ministry of Health to build the district hospital in 2007, as part of its mission to strengthen the public health system.

Kirehe is a district in Rwanda’s Eastern Province, known as the country’s breadbasket for its large-scale commercial agriculture. But with a population of nearly 450,000 served by one hospital, the demand for health care is high.

NICUs are crucial resources for newborn care, providing oxygen therapy and other lifesaving services for babies born prematurely or with complications. But mothers in Rwanda’s rural communities rarely have access to a high-quality NICU, even though the under-5 mortality rate is higher in the country’s rural areas compared to urban areas.

Newborn care at Kirehe District Hospital began with one incubator and four beds in 2009, using space in the pediatric ward. The hospital has had a NICU since 2015. The NICU cares for as many as 160 newborns each month and, along with the hospital, serves thousands of patients, including from Rwanda’s largest refugee camp, Mahama.

But before the renovations, that care came with many challenges. Bed occupancy was at 85-160%, even as demand grew year-over-year. Equipment was outdated. And there were only four wards, structured in a way that complicated care delivery and infection prevention and control.

The renovation comes as a massive step in the right direction.

Now, the NICU has five wards for at-risk infants and a total of 40 beds. The renovations also include a resting room for mothers whose babies are incubated, a “breastfeeding expression room” where mothers can breastfeed in privacy and receive training from Inshuti Mu Buzima’s “expert mothers,” and separate entrances for patients and hospital staff, expediting care and allowing an ambulance to access the unit quickly.

“As a clinician and also a mother, with the new space we have, I feel more comfortable staying in the NICU,” says Dr. Angelique Charlie Karambizi, a pediatrician with Inshuti Mu Buzima.

Even after the renovation, needs remain. The NICU needs more equipment, including five more incubators, an onsite biomedical engineer, and an upgraded laboratory.

But the newly-renovated NICU will provide lifesaving care for the youngest, most at-risk infants in Kirehe and beyond. It comes as the latest chapter in PIH’s ongoing work to dismantle longstanding injustices in global health—work that also includes Inshuti Mu Buzima’s cancer care program at Butaro District Hospital and an ongoing partnership with the University of Global Health Equity, founded by PIH in 2014 to train African doctors and nurses and shift the center of gravity in global health toward the Global South.

The NICU renovations also come as part of PIH’s decades-long partnerships with ministries of health in the countries where it works, strengthening public health systems to promote health care as a human right.

“We work towards a world where newborns and mothers not only survive, but thrive,” says Dr. Erick Baganizi, director of maternal, neonatal, child, and adolescent health at Inshuti Mu Buzima. “This will be a center of excellence for neonatal care.”

A pill could save the man’s life. But it wasn’t available in Liberia.

For months, he had suffered from an unknown disease, without access to a diagnosis or drugs. He had poured his life savings into a search for answers. But his money was running out. So was his time.

He was already skin and bones—a shell of who he once was. In a last-ditch effort, he went to Monrovia, the capital, where the country’s most advanced hospitals were located.

He brought a coffin.

It was a story that Dr. Maxo Luma and others at Partners In Health had seen too many times—patients becoming impoverished and eventually dying because they lacked access to lifesaving drugs.

Fortunately, Luma recalls, the man was able to access a diagnosis—extensively-drug resistant tuberculosis—and medication through Partners In Health.

But not all patients make it.

“Every year, millions of people die of HIV and TB,” says Luma, executive director of PIH in Liberia. “It is not really the diseases that kill them. It’s social injustice.”

Tuberculosis is 100% curable. HIV can be brought under control within six months with medication. Yet, millions of people die each year of these diseases and others, overwhelmingly in low-income countries, because they lack access to treatment and care.

That’s a reality that PIH is determined to change.

For more than 30 years, PIH has provided lifesaving drugs to millions of patients, free of charge, along with the care and essential resources they need to survive. That work is guided by a simple yet radical vision: health care is a human right.

Dying of Poverty

Years later, Dr. Carole Mitnick still remembers the lengths people would go to in order to get lifesaving drugs in Lima, Peru in the early 1990s, when treatment for multidrug-resistant tuberculosis wasn’t widely accessible.

Patients could get drugs for tuberculosis for free from the Ministry of Health; but if they needed treatment for MDR-TB, an especially deadly and drug-resistant variant of the disease, they would have to buy the medication themselves—nearly impossible for those living in Carabayllo and other communities in Lima, where the average income was as little as $1 a day.

“The stories were just heart-wrenching,” recalls Mitnick, who was doing her doctoral research with PIH in Lima at the time.

A man with MDR-TB would go to the markets in wealthy parts of town and rummage through trash in search of lemons to sell. A woman became a sex worker to afford her husband’s medication.

If patients and their families managed to buy the drugs, they would often ration supplies—cutting pills in half, taking pills every other day instead of daily, or taking them for a month and then stopping—lessening their effectiveness and putting patients at risk for even more resistant tuberculosis.

Thousands more couldn’t access the drugs at all.

By 1995, an outbreak had emerged in Carabayllo, where PIH Co-Founder Dr. Jim Kim had begun to work with Peruvian colleagues. But the growing number of deaths were ignored by the global health establishment at the time. Health leaders in the Global North argued that a disease like MDR-TB was too costly and complicated to treat in impoverished places like Carabayllo.

PIH set out to prove them wrong.

Working in partnership with Peruvian doctors and the Ministry of Health, PIH began treating patients in Carabayllo—against the advice of the global health establishment—providing drugs and care, free of charge.

Dr. Leonid Lecca, now executive director of Socios En Salud, as PIH is known in Peru, saw that work and its impact first-hand.

“I remember in the beginning, when Socios treated MDR-TB patients, we had many challenges,” he recalls. “Now, the situation is different…the MDR-TB program in Peru is due to Socios En Salud’s work.”

Thousands of lives were saved. And a growing body of evidence was created to show the world that MDR-TB was, in fact, treatable in the poorest places, contrary to what global health leaders had once claimed.

PIH’s efforts catalyzed change on a national and international level and bolstered a growing movement for global health equity. In Peru, the Ministry of Health launched a nationwide program to provide MDR-TB testing and treatment for free. And the World Health Organization updated its policies, expanding global access to lifesaving MDR-TB treatment.

“It was really transformative,” says Mitnick, who is now professor of global health and medicine at Harvard Medical School. “It was transformative for individual patients, and it was transformative for programs and clinicians.”

A Cure For Injustice

PIH’s work to make drugs free and accessible had begun years earlier, thousands of miles away in Cange, Haiti, in response to another disease.

PIH began its work in Haiti in 1983, when Co-Founders Dr. Paul Farmer and Ophelia Dahl opened a clinic in Cange, a rural village in the Central Plateau. As Farmer, Dahl, and their Haitian colleagues provided free health care to dozens of people once unserved, a deadly infectious disease was spreading worldwide.

The first case of AIDS was detected in 1981 in the United States. By 1986, more than 38,000 cases had been reported from 85 countries. AIDS is the latest and deadliest stage of infection with HIV, a virus that attacks the immune system.

“Back then, HIV was a death sentence,” says Maxo Luma, who saw friends fall ill with the disease in Haiti, where he was born and raised.

The first antiretroviral treatment for AIDS was approved in the U.S. in 1987. But the drug remained unavailable in most of the world. It was nowhere to be found in Haiti, where even the richest patients would have to fly to Miami and pay as much as $4000 per month to access it, Luma says.

At the time, global health leaders argued that treatment wasn’t a sustainable option in impoverished communities and advised prevention instead—an approach that would’ve left millions worldwide without care.

It was a status quo that PIH refused to accept.

Farmer and his colleagues—primarily Haitian doctors and nurses—decided to treat patients anyway. PIH staff bought drugs in bulk in the U.S. and took them to Haiti, sometimes in backpacks, where they were given to patients free of charge.

As its HIV work expanded, PIH joined a growing global health movement in demanding that the U.S. and other wealthy nations make HIV treatment accessible to all patients, worldwide. No patient, PIH argued, should have to die because they couldn’t afford drugs and care.

The work that began in Haiti soon spread beyond its borders.

More Than Medicine

As a young clinician in Rwinkwavu, Rwanda, Dr. Jean Claude Mugunga remembers the constant frustration of seeing pharmacy shelves empty and having to write prescriptions for patients that he couldn’t fill.

“For me, as a doctor, it was very frustrating,” he recalls. “It was so demotivating.”

No HIV drugs were available in Africa in the early 1990s, despite their availability in the U.S. and Europe. The first highly active antiretroviral combination therapy—a far more effective treatment—was approved in rich countries in the mid-1990s. But the drugs were unavailable in Africa. Only the wealthiest Rwandans could access them and, even then, would have to travel abroad and spend thousands of dollars.

Mugunga first learned of PIH as an intern at Rwinkwavu Hospital.

“I heard of PIH doctors from the U.S. coming to rural areas. They were bringing HIV drugs,” he says.

The news intrigued him.

Most international organizations in Rwanda at the time were working in major cities like Kigali, not in rural areas, he says. And doctors with PIH were providing more than medicine: they were asking if patients had food to eat.

“I was like, wow this is unheard of. No other place was doing that,” Mugunga says. “But PIH was making sure patients were coming and were not charged.”

Since its earliest years, PIH has provided not just medical care, but also essential resources like food, housing, and transportation. That work is guided by the belief that it’s not enough to hand a patient a drug or even provide a surgery—they need food, housing, transportation, and financial stability to stay on track with their recovery. In fact, those essentials, which PIH calls “social support,” often make or break whether a patient can access health care at all.

That approach has saved lives.

Mugunga, who joined PIH in 2013 and is now deputy chief medical officer, recalls seeing patients, on the brink of death, make full recoveries. Some would even join PIH, known in Rwanda as Inshuti Mu Buzima, to help their communities, becoming some of the country’s first community health workers.

The stories were a “miracle,” says Mugunga. And their impact was felt far beyond Rwinkwavu.

PIH’s HIV work helped inspire global policy change, including the creation of The Global Fund and PEPFAR—two crucial mechanisms that have enabled low-income countries to access treatment for HIV, malaria, and TB, saving millions of lives.

‘A Moral Imperative’

Even as colossal strides have been made in the fight against HIV, TB, and other infectious diseases such as hepatitis over the years, there is still much work to be done. Drugs and health care remain unaffordable for millions worldwide.

In recent years, the COVID-19 pandemic has brought new challenges to the movement for drug access, highlighting longstanding injustices in global health as wealthy nations hoarded the world’s supply of vaccines. The pandemic also deepened enduring challenges like the fight against TB.

But PIH remains committed to the work it began, decades ago. Making drugs free and accessible and saving lives, says Luma, is not a “favor.”

“It’s a moral imperative,” he says. “This is what everyone should get. We’re talking about health care. This is a basic human right.”

What struck Winston Duke the most while visiting Partners In Health in Rwanda was not the hospitals, or the medicine, or even the stories from patients and staff—it was the sense of community.

Duke, an actor and philanthropist known globally for his role in Black Panther and Black Panther: Wakanda Forever, joined PIH for a two-week trip to the East African nation in late May. PIH, known locally as Inshuti Mu Buzima, has worked in Rwanda since 2005, strengthening the health system and providing medical care and social support in partnership with the Ministry of Health.

During the trip, Duke met with patients and staff in Rwinkwavu, PIH’s first site in the country; accompanied community health workers on a house call; stayed overnight at the home of PIH Co-founder Dr. Paul Farmer, and visited PIH-supported Butaro District Hospital, currently under expansion, and the University of Global Health Equity.

It was an experience that left him feeling inspired and changed “fundamentally, forever.”

Below, Duke, who is PIH's first global ambassador, shares some key reflections from the trip and what draws him to PIH.

The conversation below has been edited and condensed.

Was there a moment that made you realize on a personal level that health care should be a human right?

During one of our first visits in Rwinkwavu, we met a woman whose life was changed—you know, a complete 180—where she was brought to PIH on the brink of death, after being found on the side of the road.

PIH helped her to combat HIV and live with the disease. They provided her a home. They then helped her to acquire land. She had children that she was separated from. She was from Tanzania, a country just right across the border, and they were able to help her get her kids from there and rebuild her entire life to the point where now she is a landowner and entrepreneur and her kids are in the best schools in Rwanda. It feels like a mountain of a story, but that is her human right. Her human right is to live. Her human right is to have access to health care—that is, not only pills and medication, but the holistic ability to live a fulfilled life.

And everyone is entitled to that—every single human being. That moment really showed me the impact of the work that PIH is doing and can do and will do in the future and that every person—no matter where they're from, no matter where they live, no matter what they were born into, no matter what circumstances have happened to them—deserves health care. That moment redefined health care for me, as something much larger.

You stayed at Paul Farmer's home for part of your stay in Rwanda. Tell us about that experience.

Yes, we stayed in Paul Farmer's home, the Friendship House. We walked in his footsteps, and that was an incredible experience to see how barebones the home was and to see that he really was just about the work. There was nothing glamorous.

The Friendship House is a space of deep intention, meaning, and impact, and it was really great to sleep in that home and see how he even had his family there and how he was part of the community—understanding how he walked the yard and picked out every tree that was planted there and why there was a meaning behind each and everything. It really conveyed to me that this man was very intentional while also being a great visionary.

We were thrilled when you expressed interest in our work in Rwanda and even more excited to welcome you here in person. What has it been like talking to doctors and patients and seeing the work up close?

It was really great to actually see the work firsthand—to see not only the patients but also the human beings dedicating their life to this kind of work, to changing the health systems and making them way more equitable and accessible for people all over the world.

And in a place like Rwanda—which is both a place of incredible beauty, personality, very individualistic heritage and nuanced history and also a place of great need—seeing these doctors show up every single day and give their lives, give their blood and sweat, was just something that was incredibly enriching to my life. I'm really going to take that message with me as I move forward, seeing the kids that they're working with and how they're changing the health care systems to combat all the -isms of the world, white supremacy, racism, implicit biases.

It was really incredible to see that. And it's changed me, fundamentally, forever.

Trips like this can bring about a lot of feelings and thoughts. If you were to try to condense how you're feeling now at the end of this trip into a word, what word would you choose and why?

Inspired. I'm inspired to carry forward the mission of Partners In Health. I'm inspired to change how we see health care and redefine a lot of the words that we use in our everyday life that have lost meaning and become a bit mundane. Health care is one of those words where we take it for granted, and we think that it just means a trip to the hospital, being able to see a doctor, having access to medication. But it's so much more. It's community. It's fulfillment of dreams. It's people being able to feel like they are recognized and empowered. It is so much more. It's family—it's creating family, it's redefining family, it's creating a global family. And I think that's what Partners In Health has inspired me to do—to really just reframe and redefine a lot of the words, and contexts that we use those words in, day to day.

To truly understand Dr. Benoucheca Pierre, it’s worth recounting her recent travels to Madagascar, where she lead physicians creating new national standards for delivering medical oxygen to patients.  

In July, Pierre, chief of the ICU at Hôpital Universitaire de Mirebalais, couldn’t fly out of Haiti, where she was born and lives, because all direct flights to Europe had been canceled in the wake of an escalating security crisis marked by nationwide violence and fuel shortages.   

So, she drove about six hours to the Dominican Republic, boarded a plane to Paris, waited 12 hours and then continued on to Mauritius. But because her COVID-19 test had expired prior to her final flight to Madagascar, Pierre was prohibited from boarding. And, without a local hotel reservation, she was detained in immigration. After several hours of fraught calls, Pierre was able to book a hotel and secure a flight that connected to Madagascar through Reunion Island, which sits in the Indian Ocean as a department, or region, of France. Holding a French visa, Pierre assumed there would be no problem traveling this route. However, officials told her that her French visa was unacceptable, and she would have to wait for a direct flight the next day. 

“So, 48 hours after she finally lands, she leads the workshop,” said Dr. Paul Sonenthal, an associate physician in the division of pulmonary and critical care medicine at Brigham and Women’s Hospital in Boston and director of inpatient medicine and critical care for Partners In Health. “There was never a moment where she said, ‘Maybe I shouldn’t do this.’"

He added: “I have the deepest respect and admiration for her commitment,” 

‘I Am a Doctor’ 

The daughter of an artist and salesman, Pierre grew up in Port-au-Prince where she attended high school and worked at her local church. “I wanted to be a doctor because I worked with the kids at church, and I was very interested in keeping them healthy,” she said. Following her medical studies at Notre Dame University, Pierre received a prestigious fellowship in France, training in anesthesiology and critical care. But rather than accept a lucrative position in Europe, Pierre returned home to Haiti, specifically to Hôpital Universitaire de Mirebalais, the teaching hospital run by Haiti’s Ministry of Health and Zanmi Lasante, as Partners In Health is known in Haiti.  There, she said, “I could continue my learning in intensive care.”  

Indeed, Pierre not only continued learning; she became the chief of the unit and, in the country’s public sector, the only ICU-trained doctor in Haiti. She remains one of only two intensivists in the country. “She has a singular and unique set of world class skills and expertise that she is sharing with the nation,” Sonenthal added.  

Even before the pandemic hit, he said, Pierre was busy directing the planning and establishment of the country’s first COVID-19 treatment unit at HUM. When ill patients began arriving with the virus, and other doctors feared coming into the clinic, Pierre did not hesitate and remained on call essentially 24/7, said her colleague, Dr. Christophe Millien, chief medical officer at HUM.

“She said, ‘I am a doctor. It is my responsibility to take care of patients,’” Millien said.  

Sharing Oxygen Expertise  

At that point, there was a dearth of knowledge or standards on effective oxygen administration in Haiti, Sonenthal said.  There were no protocols in place that detailed the correct amount of oxygen given in certain cases, or whether it was best to use a nasal cannula, face mask, or breathing tube, he said. That’s when Pierre took charge, recognizing an opportunity to build the hospital’s critical care capacity.  

“She essentially developed all the protocols for oxygen therapy for COVID-19 patients at HUM and then took that to the national level throughout Haiti,” he said, adding that in less than a year, Pierre’s physicians “were fully capable of independently managing patients on ventilators, adjusting settings and sedation to ensure the provision of lung protective ventilation.” Then, she expanded the curriculum nationwide, he said, training dozens more clinicians, while continuing to oversee care for patients at HUM. 

Now, Pierre is spreading her oxygen expertise into other regions as a senior expert advisor in Madagascar for BRING O2  a Partners In Health-led initiative to increase access to safe, reliable medical oxygen in five countries—Malawi, Rwanda, Peru, Lesotho, and Madagascar. The effort is funded by Unitaid, in partnership with Build Health International and PIVOT Health Madagascar. 

Pierre’s job is to support the medical professionals in Madagascar, where there had been no standard oxygen guidelines; to develop national oxygen protocols, and to advise professional training  

An Unsung Hero 

Pierre’s efforts have led her to be nominated for an “Unsung Hero” award from the organization Reaching the Last Mile. In his nomination, Sonenthal wrote: 

“She has remained committed to these activities despite the rising level of insecurity in Haiti. For extended periods, when the commute from home became too dangerous, Dr. Pierre has opted to live within HUM’s grounds so she could continue to serve her patients.”  

Millien noted Pierre’s ability to both teach and mentor other physicians while also delivering top-notch, compassionate care for patients and saving countless lives.   

Sonenthal recalls one of Pierre’s patients, a 20-year-old who’d had a severe asthma attack and needed to be placed on a ventilator. “The odds of him surviving in a U.S. ER were 50/50,” Sonenthal said. He and Pierre consulted back and forth for days and into the night as the patient’s condition fluctuated, from stable to being on the “brink of death,” with airways so narrow that too much outside oxygen pressure could blow out a lung and prove fatal.  

Due to Pierre’s “quick response and recognition” of the patient’s condition and her “subtle, elegant” shifts on the ventilator, he survived.  

Pierre said she often keeps in touch with her patients. She remembers a recent case, a man who had to be intubated: “I remember he told me, ‘Doctor you are going to make me sleep and not wake up, and I am the only one working in my family, I am the only provider,’” she said. “I told him we would give him the very best care. He was a very big challenge, intubated for two weeks. Then when he was discharged, we celebrated with the family.” 

Pierre continues to face dire conditions in Haiti, most recently an oxygen shortage with one of the main hospitals reporting limited supply and patients at risk. 

“All the main health structures of the country are on alert, such as the General Hospital, because they depend on external oxygen supplies, ” Pierre said. “At the University Hospital of Mirebalais, we have two oxygen generators on site that completely fill our need for oxygen for the good of our patients. The second one, not yet operational, was donated by the Ministry of Public Health in the midst of the fight against COVID-19....So in the last few weeks we have been more affected by the fuel shortage as we are struggling to provide continuous power to the hospital and our sites.” 

Her ability to persevere through such difficulties is unique, colleagues said. Pierre’s grueling trip to Madagascar is an “illustration of the complex barriers she faces,” according to Sonenthal. “It was not easy for her to get there, there were so many barriers, but she persisted, she never wavered. She is my greatest clinical hero.” 

The Sierra Leone Psychiatric Teaching Hospital (SLPTH) has received a formal 5-year accreditation  for the first-ever psychiatry residency program in the country. With this accreditation, Sierra Leone will be able to train its own psychiatrists for the first time, while strengthening the capacity of other health professionals in mental health care delivery.  

“It is a huge accomplishment for the nation and a testament to the hard work and resources that we have put into the development of mental health treatment in our country,” says Dr. Jusu Mattia, one of seven residents in the program. 

The Partners In Health (PIH)-supported facility was accredited by the West African College of Physicians, an association of medical specialists that promote professional training of physicians in West Africa to improve standards of practice and specialty training.  

In order to receive accreditation, hospitals must submit an application and coordinate a visit for an assessment of the facility.  Some of the factors assessed include: human resources capacity, including presence of a neurologist to train residents; infrastructure capacity, including a laboratory to run tests and monitor medications; quality of the drug rehab therapy program, as well as child and adolescent services; and the condition of triage and outpatient supplies and other essential equipment like ECT and EEG machines, among other criteria.  Once the assessment is complete, the findings are then shared with the board and applicants await a decision.  

While the process was extensive, the SLPTH accreditation team met the requirements and received full accreditation on the first attempt.  

Much-Needed Training, Support 

The accreditation is a huge accomplishment, not only for the hospital but also for the nation. There are currently only three psychiatrists in the country, which is home to more than eight million people. And for many years, there was one psychiatrist. Additionally, psychiatric training wasn’t available.   

“As a result, medical doctors like myself were required to receive psychiatric training in a foreign country. We will no longer need to [do that], which will increase the human resources in mental health care,” says Dr. Haja Abibatu Jalloh, a resident in the first cohort. “For me, it is like a dream come true!” 

This in-country training will increase the retention of doctors, while also attracting doctors from other countries to receive psychiatric training. 

With the partnership and continued support of PIH and Harvard Medical School, the program will expose doctors to evidence-based practices and serve as an opportunity for cross-site learning. By training with and learning from medical professionals with various backgrounds and knowledge, residents will be equipped to practice anywhere around the globe.  

The residency program will serve as a hub for building, expanding, and strengthening mental health care in the country. It will not only train specialists in psychiatry but will also build the capacity of other health care professionals in the delivery of mental health services as well as providing strategic leadership, planning, and administration at government and international levels. The specialists will provide leadership in a multi-disciplinary mental health team, at all levels of care, provide effective teaching to all categories of health workers and public groups, and be able to carry out relevant research in the field of global mental health and related disciplines.   

“I am so excited to be part of this amazing accomplishment that gives hope to people who for decades have been abandoned, isolated, chained, starved, and hugely stigmatized because of their mental health problems,” says Chenjezo G. Gonani, PIH’s mental health program manager. 

Previously known as Kissy Mental Hospital, SLPTH is the oldest psychiatric hospital in sub-Saharan Africa and the only dedicated psychiatric hospital in Sierra Leone. Once an under resourced facility, it has since transformed into a hospital capable of providing comprehensive clinical services and teaching the next generation of medical professionals. Through a partnership with PIH in 2018, the team progressed from an average of 40 to 75 monthly outpatient visits to 75 to 300 monthly  visits since the start of the program. The improved services have also resulted in an increased number of new patients coming from other districts, given that SLPTH now offers some of the best services in the country. Through infrastructure improvements for care delivery, renovations of patient wards and grounds, and improving monitoring of patients, the hospital has been able to expand clinical services for substance use, launch a child and adolescent mental health unit, and offer treatment for urgent mental health diagnosis. 

With the recently announced accreditation, SLPTH staff and residents hope the hospital and residency program will become an example of the quality of care that is possible in the country and region, while giving patients the mental health care they deserve.

Cory McMahon, chief nursing officer at Partners In Health, writes below about her daughter with Down syndrome and the many global inequities surrounding the care and treatment of children with developmental disabilities.

I often reflect on Paul Farmer’s words: “The idea that some lives matter less is the root of all that is wrong in the world.” As chief nursing officer at Partners In Health, this call to action drives our nursing efforts in some of the world’s most resource-limited countries. As the mother of a child with disabilities, Paul’s radical sentiment on worldwide humanity hits close to home. My daughter, Mali, now 9 years old, has Down syndrome. She faces a lifetime of navigating an exclusionary society full of barriers for people with Down syndrome and other developmental disabilities.

I was working for the Human Resources for Health initiative in Rwanda prior to Mali’s birth. My partner and I came back to the United States for her delivery, always planning to return to Rwanda. But when we learned that our daughter was born with Down syndrome and grasped the full extent of Mali’s needs, we decided to remain in the U.S., where we had full access to medical specialists and social support networks, including our own family and friends and a strong Down syndrome community. The decision to stay was complex and wrought with mixed emotions.

The privilege we were afforded simply by being born in the U.S. became abundantly clear; because of that simple fact we knew Mali could get top-quality care from a team of practitioners and specialists throughout her life.

A Whirlwind of Care

And care she got: from her earliest days there would be a whirlwind of tests and appointments, medical and child development experts. We were connected to a Down syndrome clinic, ensuring that Mali was getting the medical care she needed from a multidisciplinary team. We received services in our home from the time Mali was four weeks old that supported her growth and development and now those services continue in school. We had an entire community and resources to support us – we were not alone.

But even with this top-notch care, the message we got was often about what Mali couldn’t do—communicating a constant reminder that she will not develop the same way, or at the same pace, as other children. Soon, though, Mali became my biggest teacher, evolving my own beliefs of what’s possible for her day by day. Each milestone, while not on the same timescale as most children, was another step toward a fulfilling, happy life.

Few Services, High Stigma

I often wonder what our experience would have been like in Rwanda. In 2012, when Mali was born, there were few—if any—medical, therapeutic, and supportive services we needed. The stigma associated with Down syndrome in many parts of the world remains a reality that further prevents parents from accessing care. This stigma inhibits more than just access to medical care, it also limits access to community and resources that would help families navigate this often difficult terrain.  This lack of resources and support also conveys a strong message: some lives matter less.

Rwanda has made tremendous progress. Today, there is a pediatric development center that has enrolled over 2,500 children and families. This center, the first of which opened at Rwinkwavu District Hospital in 2014, provides comprehensive services including physiotherapy, occupational therapy, nutrition services, screenings for vision and hearing impairments, and caregiver groups to teach parents ways to play and interact with their children that promote early childhood development. The center focuses on engaging fathers who were often abandoning their families, leaving mothers alone to care for their children with complex needs. In recent years, the center has served as a model that has since expanded to 18 public health centers in PIH-supported facilities across Kirehe and Rwinkwavu Districts and into Malawi. 

The Work Ahead

Globally, there is still much more work to be done to meet the needs of this unique population and others with developmental delays and disabilities. Accessing diagnostic testing and a lack of country-wide birth registries remains an enormous challenge. As a result, we don’t track or know how many people are born or live with Down syndrome around the world.

Without a diagnosis, many families are unable to obtain necessary medical, psychosocial, and caregiver supports needed. Approximately half of all babies born with Down syndrome have congenital heart conditions, requiring access to specialized services like cardiac surgery and neonatal intensive care units. Gastrointestinal abnormalities, thyroid conditions, immune disorders, respiratory complications, hearing and vision impairments, and childhood leukemia are other complex medical conditions associated with Down syndrome requiring specialized care. Children born with Down syndrome have low muscle tone and experience difficulty latching on during breastfeeding; they, therefore, run a higher risk of malnutrition. These mothers and infants require additional support, and, when necessary, nutritional supplementation, which is often inaccessible.

Most of these conditions are treatable, allowing people with Down syndrome to lead healthy, productive lives. Without these interventions there is a higher mortality rate and lower quality of life, preventing individuals from meeting their full potential and the community from benefiting from the unique contributions of this population.

No Child Matters Less

We can and must do better. In the U.S., the life expectancy for people with Down syndrome has increased from just 9 years in the 1920s to now close to 60 years. Access to comprehensive health care and increased community acceptance have all contributed to improved life expectancy and quality of life. People with Down syndrome are business owners, teachers, models, actors, marathon runners, daughters, sisters, and a loving, irreplaceable, integral life force in a family. And the list goes on. It is our moral and social imperative to include people with Down syndrome and other disabilities in the global discourse and ensure the right to health care, autonomy, community integration, financial security, and opportunity.

No child matters less because they are born with a disability.

Paul’s call to challenge conventional beliefs, and to disrupt the status quo, forges a healthy and dignified path forward for children with Down syndrome like Mali. Heeding his words would give all children, no matter what their special needs might be, the opportunity to live healthy and fulfilling lives.

Marí Romero Sánchez first felt the lump while she was changing clothes. It was in her right breast—not painful, but hard and growing.

Sánchez, 50, had already faced a string of health scares over the past year, including COVID-19 and a motorcycle accident. She dreaded the thought of another. But, she and her daughter reasoned, it was better safe than sorry.

Reluctantly, she went to the Villa Clorinda Medical Center, about 15 minutes from her home in Cómas, in February.

There, an OB-GYN examined the lump and delivered some unsettling news: it could be a sign of breast cancer; she would need a mammogram.

Breast cancer is the most common cancer worldwide and in Peru, where more than 6,800 cases were detected in 2020. But 75% of cancer cases in Peru aren’t diagnosed until the advanced stage, resulting in deaths that could have been prevented with wider access to screening.

Mammograms—critical tools for early detection of breast cancer—are not available in impoverished communities like Cómas, a district in northern Lima. To access this service, patients must get a referral to a hospital—typically, hours away and fraught with complex referral procedures and long waitlists.

Socios En Salud, as Partners In Health is known in Peru, is determined to help as many patients as possible beat the odds—accessing screening, diagnoses, and lifesaving care.

Early Detection

Socios En Salud has worked in Peru for more than 25 years, ever since it responded to a deadly outbreak of multidrug-resistant tuberculosis in Carabayllo. In the years since, Socios En Salud has expanded its medical care and social support programs and strengthened the health system in partnership with the Ministry of Health.

Breast cancer care has been part of that work for years. Through the Aceleración de descarte de Lesiones de Mama (ALMA) program, which began in August 2020, Socios En Salud dispatches its team of community health workers—locals hired and trained in basic health services—to proactively find women over 40 years old in Cómas and Carabayllo, two impoverished districts in northern Lima, and educate them about breast cancer and health services available to them. This outreach is conducted in markets, soup kitchens, neighborhoods, and clinics.

The impact is immense.

Last year, Socios En Salud provided breast cancer screenings to more than 1,886 women in northern Lima.

Sánchez was one of hundreds of women connected with a mammogram this year. The result was what she feared: breast cancer.

She would need several rounds of chemotherapy to treat the cancer, which was in stage two. Each session would be five hours long and in a city hours from her home, taking her away from her daughter and grandchildren.

“I suffered from depression during the first several months,” she says. “But life goes on.”

‘A Long Road Ahead’

The chemotherapy began in May. During her first appointment, she was so nervous that her blood pressure dropped. Fortunately, she was not alone.

María Rosas, a community health worker with Socios En Salud, was there to support her, helping her navigate the hospital and referral process and staying by her side for the five-hour session.

"She accompanied me and was with me during the first chemotherapy, giving me strength and encouragement,” says Sánchez.

After she completed the first round, Rosas continued to accompany her, checking in regularly. Socios En Salud also connected Sánchez with a therapist—care that its mental health team routinely provides for patients with chronic conditions, which can contribute to anxiety, depression, and other mental health conditions.

“Marí is a very strong woman,” says Rosas. “From the first day of treatment, she knew that it would be a long road ahead and that the medical team of Socios En Salud would be with her at all times.”

That support proved crucial for Sánchez, as the treatment took a toll on her physical and mental health.

“After the first round of chemotherapy, my hair started to fall out,” she recalls.

She began wearing a turban. She noticed a drop in her energy, too. In the morning, she felt dizzy and nauseous, leading her to take a pill to cope with the side effects.

It was a process that would more or less repeat itself every 21 days, when Sánchez was due for her next round of chemotherapy—a moment she dreaded, not just for the discomfort, but also for how it took her away from family.

But she knew she had support.

“Socios En Salud has been by my side, from the time I was diagnosed until today,” she says. “I feel accompanied.”

And the treatment was working. Month by month, she felt her strength returning to her. After four rounds of chemotherapy, the lump in her breast had shrunk from three centimeters to one.

For the first time in months, she felt relief—and hope.

“Many people think that cancer is synonymous with death, but science has come a long way,” she says. “I am confident that I will be cured.”

Aline Niyizurugero, then 16, was heading home from school with her friend.

They had brought mangoes for her father and brother, who were at home cooking lunch. But when she was half a mile from her home in Kabarondo, a village bordering a busy road to a national park, a speeding motorcycle hit her from behind.

She was knocked unconscious.

Within minutes, the news got to her father Benjamin Shumbusho, from the neighbors. He rushed to the roadside to see her, fearing that he would lose his only daughter. The family of three had already suffered the loss of Niyizurugero’s mother, when she was just a baby. Another death would be devastating.

When he arrived and found his daughter, laying on the side of the road, he thought she was dead.

“I didn’t think she was still breathing,” said Shumbusho.

Desperate, he called an ambulance, knowing that emergency services could take an hour or more to arrive. The next several hours were a blur.

Niyizurugero was rushed by ambulance to the emergency room at Rwinkwavu Hospital, one of several hospitals in Rwanda supported by Partners In Health.

Advanced Care

Inshuti Mu Buzima, as Partners In Health is known locally, has worked in Rwanda since 2005, supporting the Ministry of Health to strengthen the health system. Rwinkwavu District Hospital was the first fruit of that collaboration. In 2005, PIH transformed the broken-down facility in Rwinkwavu into a functional district hospital.

There, in the emergency room, Niyizurugero received lifesaving care, stabilizing her, though she was in a coma. But she had suffered injuries to her head and legs that would require advanced care—and a trip to a referral hospital in Kigali, some hours away.

Many families in Rwinkwavu live on less than 3 dollars a day and survive on subsistence farming, barely making enough to make ends meet, much less afford medical bills. Niyizurugero would need multiple surgeries for her head and leg and intubation to help her breathe. Such procedures are typically costly—far out of reach for most families in rural Rwanda.

Still, Shumbusho would stop at nothing to save his daughter.

“I was willing to do anything to see my daughter alive again,” he said. “I had no health insurance nor money. I was going to sell everything for the treatment of my daughter.”

It was a desperate measure that, fortunately, he never had to take. Just two days later, as his daughter remained in the hospital, staff with Inshuti Mu Buzima reached out with life-changing news.

“A lady I hadn’t met before approached me,” he recalled. “Her words at that time gave me the hope I needed. She worked with Partners In Health. She said they will be covering my bills 100% percent.”

Right to Health Care

Inshuti Mu Buzima works with several referral hospitals, which are mainly in cities like Kigali and far away from the rural areas where PIH works. Even though health care is generally accessible in Rwanda, such care comes with many hidden expenses, such as transportation, lodging, and meals. These costs are only amplified when it comes to advanced care, which often requires hours of travel and accommodation in a major city, for extended periods of time—putting this care financially out of reach for many patients and families.

To address this issue, PIH established the Right to Health Care program in the countries where it works. The program supports patients with coverage of medical bills, essentials like food and clothes, follow up care, and funeral arrangements in case of death.

“Our role is to support patients who require treatment outside the district hospitals,” said Dorcas Sifa, who manages the Right to Health Care program in Rwanda. “In a month, we support over 100 outpatients and between 30-40 inpatients.”

In Rwanda, the Right to Health Care program has served more than 4,000 patients.

That support is crucial for patients like Niyizurugero.

After nearly a month of surgeries, including multiple procedures at different hospitals, Shumbusho saw his daughter’s eyes open. She couldn’t move, speak, or eat. But she was conscious, again.

“I felt like I was tied to the bed,” she later recalled. “I didn’t know what was going on. I just wanted to go home.”

It would take two more months for her to return home. Support from the Right to Health Care program didn’t end there. Inshuti Mu Buzima staff regularly checked in with her, helped her get medications and schedule appointments, and provided financial assistance.

Inshuti Mu Buzima is also working in partnership with the Ministry of Health to strengthen the surgery ward at Rwinkwavu District Hospital by expanding the space, hiring new staff, and buying new equipment.

More than a year later, Niyizurugero reached another milestone: she started walking and speaking again.

She began dreaming again, too. As school approaches, she hopes to return to class and finish her primary education.

“I feel ready to sit in the classroom with my friends,” she said.

This information was updated on October 17.

A recent cholera outbreak in Haiti, announced by the Haitian Ministry of Public Health and Population earlier this month, is adding turmoil to the country’s escalating troubles, where gang violence, damaged communications systems, and dire fuel shortages have increased over the past 15 months. 

The medical team at Zanmi Lasante, as Partners in Health is known in Haiti, reports there are seven suspected cholera cases being treated at Hôpital Universitaire de Mirebalais as of October 17, five adults and two children. 

Anticipating more cases to come, the team has converted one of its COVID centers into a cholera treatment center, with an 18-bed capacity. 

Children Most Affected 

As of October 12, the Haitian Ministry of Health reported 384 suspected cases of cholera; 43 laboratory-confirmed cases; 197 people hospitalized and 22 deaths. Of the total reported cases, 53% are male and 46% are female. The most affected age group is 1 to 4-year-olds.

ZL has been distributing food and hygiene supplies to staff and trying to procure fuel to keep medical sites running. The team is also working with international partners to rapidly distribute essential supplies to respond to cholera. To date, not one ZL facility has closed or been forced to stop caring for patients throughout the region. Indeed, 1.3 million people, or 1 in 10 Haitians, rely on ZL-supported facilities for care, treatment, and accompaniment.      

Previous Outbreaks 

Haitians never experienced cholera before 2010. Then, just after the devastating earthquake that year, UN peacekeepers arrived in the country from Nepal, which had recently suffered a cholera outbreak, and set up operations in a camp near Mirebalais with poor plumbing. Contaminated sewage leaked into a tributary of the longest river in Haiti, the 200-mile Artibonite river, which is a water source for countless Haitians.  

This led to a massive cholera outbreak: more than 9,700 people died and at least another 815,000 were sickened from the disease. Cholera causes such severe vomiting and diarrhea that—if left untreated—a patient can die from dehydration within 24 hours. Many victims are children. 

Mass Vaccination Efforts 

PIH was among the first responders to the 2010 outbreak in Haiti. Within several months, staff set up 11 cholera treatment facilities throughout the Central Plateau and lower-Artibonite and immediately began treating the sick. More than 3,300 community health workers were trained to identify symptoms and triage neighbors to nearby health centers. Ultimately, PIH treated more than 180,000 people.  

Doctors, nurses, and community health workers also worked to prevent cholera infections by teaching about proper water and sanitation practices and vaccinating as many patients as possible, which boosts immunity for up to five years. In 2012, PIH vaccinated 50,000 people in communities north of St. Marc. And following Hurricane Matthew in 2016, leaders traveled to the south to help the government vaccinate 800,000 residents. 

That campaign was followed by another effort in 2017: ZL, in collaboration with the national Ministry of Health and Massachusetts General Hospital's Center for Global Health, launched a vaccination campaign that aimed to cover the entire commune of Mirebalais, or roughly 100,000 people. Each resident received two doses of the vaccine over the course of a month, along with interventions to help treat drinking water at home and educational messages about good hygiene and sanitation. 

Read More About Cholera

The University of Global Health Equity (UGHE) in Rwanda has earned regional accreditation for its medical school, furthering its mission to radically transform global health education and care delivery.

The university was accredited following an inspection by the East African Community (EAC), an intergovernmental organization comprised of seven states: Rwanda, Uganda, Tanzania, Kenya, the Democratic Republic of the Congo, Burundi, and South Sudan.

The EAC’s Council of Higher Education inspected UGHE’s campus in Butaro, Rwanda in September, along with its teaching hospital, Butaro District Hospital.

The accreditation paves the way for UGHE to deepen its collaboration with regional and international institutions and affirms its standing as a leader in global health education.

“UGHE is proud to be among the universities in Rwanda with the EAC regional accreditation and this will go a long way in extending our unique educational pedagogy,” said UGHE Vice Chancellor Dr. Agnes Binagwaho.

UGHE was founded by Partners In Health in 2015, in collaboration with the Rwandan Ministry of Health. The School of Medicine opened in 2019, offering a bachelor’s level medical degree coupled with a master’s level global health degree.

With comprehensive classes, intensive clinical internships, and hands-on practicums, the school trains the next generation of doctors, nurses, and global health leaders to deliver medical care rooted in social justice.

And that education isn’t limited to a classroom—the campus extends to Butaro District Hospital, where students put their skills into practice, and to the rural communities in Butaro, where Partners In Health, known locally as Inshuti Mu Buzima, has provided medical care and social support for more than 15 years.

After graduating, students serve six to nine years with the ministries of health in their home countries—service commitments that place them in underserved communities ranging from rural areas to refugee camps.

This is all part of the university’s strategy to upend inequities in global health, a field that has historically excluded doctors, nurses, scholars, and other leaders from the Global South. With each graduating class, UGHE seeks to shift the center of gravity from where it has traditionally been, within higher-income countries, to lower-income countries—specifically, within Africa.

The continent bears 27% of the global burden of disease but has just 1.7% of the world’s doctors. UGHE students come from all over Africa, with the most recent cohort representing more than 23 countries.

UGHE’s mission—to level the playing field in global health—has earned it international recognition. In February, the university was highlighted by the United Nations’ education agency as a model for global health education.

The accreditation comes as the latest evidence of the university’s far-reaching impact.

“UGHE continues to create a cradle of unique solutions that drive systemic change, in a way that others have not,” said Binagwaho, “based on our principle that equity in quality health services delivery starts with equity in access to quality education.”

There were few, if any, mental health care options for the 64-year-old woman in Chiapas, Mexico, who suffered from depression, anxiety, and social isolation. That’s because for every 100,000 residents in the country, there is barely a single psychiatrist, and most work in major urban cities. People who live in rural regions with mental health conditions must travel as much as six to nine hours for such care, according to a report in the journal Intervention. 

Enter Problem Management Plus, or PM+, a novel psychological support intervention developed by the World Health Organization and adapted in different countries and contexts by the cross-site mental health team at Partners In Health. Through PM+, the woman* from Chiapas was able to receive help that not only improved her symptoms, but also her outlook on life.  

“She was very content when we finished PM+ sessions,” reported Carolina Guzmán Roblero, her community mental health worker  with Compañeros En Salud, as PIH is known in Mexico.  “I would continue visiting her every once in a while…because we are also part of the community and our patients will always be regarded as our patients, so we will never abandon them. Whenever I found her listening to the radio, I would feel very joyful.” 

Problem Management Plus 

Over 5 billion people worldwide suffering from mental health conditions cannot access appropriate care, contributing to already-high disease burdens for nations around the world. According to the World Health Organization: “The failure to deliver effective mental health care to over 80% of people who need it represents the single most significant challenge for global mental health.” 

To bridge this gap, the WHO developed the PM+ intervention, which can be provided by lay practitioners and licensed mental health clinicians alike, to support adults living in poverty and afflicted with emotional, psychological, or daily life problems. Its goals are straightforward: to alleviate disabling symptoms and assist patients to develop new coping skills, such as stress management, general problem solving, behavioral change, and a stronger social support system. 

The five-session program “gives the space for people to narrate their stories for the very first time,” said Dr. Fátima Rodriguez, mental health coordinator for Compañeros En Salud. “Some arrive saying they haven’t told this story before, like telling about their abuse as a child…also knowing that other people have been through the same situation, have the same symptoms, it brings hope to know these symptoms can be treated.”  

Mental Health Care Across Sites 

Mental health care is embedded within primary care and at every PIH site, said Sarah Singer, PIH’s associate director of program & partnerships for mental health.  “The cross-site mental health program is an innovative and unique example of clinical integration and knowledge across sites.”  

Since 2016, working closely with local practitioners and community mental health experts, PIH has adapted the PM+ model in Peru, Rwanda, Mexico, and Malawi—with other sites exploring future adaptation of the intervention. Analyzing the cross-site development of these programs in a 2021 article published as well in Intervention, PIH authors concluded: “Our experience demonstrates PM+ is translatable across cultures and feasible for use in real-world public sector primary care and community contexts.” 

Every aspect of the program is refined to meet the needs of each site. In Mexico, for example, providers undergo three weeks of mental health training, including modules on basic mental health topics and accompaniment, specific PM+ skills, trauma-informed care and also suicide risk assessment. Other sites offer variations of this training, including ongoing clinical supervision.  

Symptoms are ‘Culture Bound’ 

Mental health is, of course, cultural, so listening and adapting to each region's customs, language, and beliefs is critical, said Dr. Ksakrad Kelly, PIH’s cross-site senior psychotherapy technical advisor.  

“There’s a recognition that symptoms are culture bound,” Kelly said. “Depression, anxiety, and trauma can be very different, even within one household.” It’s this degree of specificity that is explored and developed in PIH’s adaptation process, she said, adding, “there’s not a specific standard approach; we let the sites take the lead.” 

For example, Kelly said, one standard question on a widely used depression screening tool is, “How often do you feel angry?” In Liberia, where the team implements other types of psychotherapy, the word “angry” is not used, so instead a word closer to “vexxed” replaced it in the questionnaire.   

In Mexico, for instance, one measure used to evaluate a person’s clinical functioning is whether they look disheveled or haven’t taken the time to arrange themselves. But “being disheveled doesn’t reflect if you’re depressed or not,” said Rodriguez, also the lead author on a paper detailing the adaptation of PM+ in Chiapas. 

The disheveled question is gone, Rodriguez said. Now, there are four questions that remain as the most relevant when assessing daily life functioning. Patients are asked whether they are having trouble sleeping, eating, with interpersonal relationships, or dealing with routine domestic tasks.  

Care delivery focuses on each individual patient’s needs and can include a combination of cognitive behavioral therapy, a kind of intentional reframing of problems, as well as relaxation techniques and “behavior activation,” which involves the deliberate practice of certain healthy behaviors to jump-start a more positive emotional state.  

In Malawi, for instance, the team adapted PM+ materials for group settings and trained lay mental health counselors to screen mothers for depression at routine prenatal visits in an effort to treat depression in pregnant and postpartum women. Like all of PIH’s mental health work, care delivery sites determine the priority needs of their communities and tailor the relevant interventions to fit those needs. 

Establishing a Connection 

Rodriguez cited another example in Mexico that involved flipping a script with patients to work through barriers. This, of course, could only be done by establishing strong relationships, she said. 

Initially, patient evaluations began with a checklist of clinical signs and symptoms, followed by a discussion that delved deeper into personal and psychological challenges, Rodriguez said. Health workers noticed that people were somewhat hesitant when the visit launched straight into a just-the-facts medical questionnaire, so they decided to begin each visit with conversation to try to establish rapport with patients who may have been hesitant to reveal personal information. Now, the health workers spend “a considerable amount of time,” around 20 minutes, conversing, before they ask about symptoms.   

“We inverted that order, because the patients told us they would feel the conversation was very abrupt” when workers launched right into the clinical checklist, Rodriguez said. “That’s how Mexico works. We are a lot about conversation, being warm.” 

Clear Mental Health Impact 

Data on the program in Chiapas shows the program’s success: 

About 70% of people who have been through PM+ reported a reduction in clinical symptoms, Rodriguez said. Currently 280 patients have enrolled in the program, and its managers have now widened the criteria for eligibility to include people experiencing gender or sexual violence, which impacts more than 68% of women in the community.   

“Through COVID, there weren’t any other providers addressing any of this, so we opened up criteria [for participation],” Rodriguez said.  

To date, almost 7,000 people have received PM+ across PIH’s four sites implementing the intervention, administrators said. 

And the approach continues to spread. PIH’s mental health adaptations around the world are now extending to the U.S., Singer said. Currently, PIH is working with a Massachusetts-based foundation and the nonprofit, The Family Van—through its Healthy Roads Program—to provide technical assistance on how to adapt PM+ for community-based organizations looking to provide mental health support across the Commonwealth of Massachusetts.

“Here’s a genuine opportunity for bi-directional knowledge exchange,” Singer added. “This is core to PIH’s mission and here’s a true example of making it work.”  

*Name has been withheld to protect the patient’s privacy 

Content warning: This story relates to suicide.

Ángel Morales is 32 years old and originally from Laguna del Cofre, Chiapas. For most of his life, Morales, like many farmers in his community, dedicated himself to growing coffee and corn—crops that provide income for him and his wife and children.

Chiapas is one of the poorest states in Mexico; many are forced to migrate to higher income countries such as the United States to seek better opportunities for their families. In 2021, Morales migrated to work "up north." That’s when the health problems started.

While Morales was working in the U.S., he was diagnosed with the stomach flu. Fortunately, he was able to access medical care and antibiotics and recovered. But the memory of that experience still haunted him. Negative thoughts began to snowball in his mind. What if he had experienced some serious and complicated illness? What if this illness had led to his death? What would happen to his wife and children if he was missing?

He started to isolate himself and stopped sleeping, eating, and working. He was no longer the man he had been months before. Everywhere he went, guilt, shame, and sadness seemed to follow.

He decided to return to Mexico and live with his family again. But the thoughts only grew worse.

"I couldn't control my nerves," he recalls. "I had panic attacks [and] headaches. My whole body ached and I couldn't sleep."

He began to lose hope that he would ever recover. Slowly, the impulse to take his own life became stronger and stronger.

It was at a local clinic, just steps away from his home in Laguna del Cofre, that he found help.

Morales had come to the clinic seeking treatment for the panic attacks and other physical symptoms. During his appointment, he also received a mental health screening, which led to a diagnosis: anxiety and acute depression. Within days, he began treatment, including medication and psychotherapy, working with one of the nine community mental health workers hired and trained by Partners In Health.

Comprehensive Care

Partners In Health, known locally as Compañeros En Salud, has worked in Mexico since 2011, partnering with the Ministry of Health to provide medical care and social support in the rural communities of the Sierra Madre region of Chiapas. Since 2014, Compañeros En Salud has provided mental health care at local clinics and through house calls from community health workers—care that, before the program, would have been at least five hours away.

In the years since, hundreds of patients have been able to access mental health care in an area once underserved. Between July 2018 and June 2021, Compañeros En Salud helped more than 1,200 patients access treatment for mental health conditions like depression, anxiety, and schizophrenia.

Mental health conditions have been on the rise globally, as people grapple with challenges such as the pandemic, climate change, and global inequities. Many factors put people at risk of suicide, including mental health conditions, substance use, lack of a strong support network, and physical, sexual or psychological violence.

More than 700,000 people die of suicide each year; 77% of global suicides occur in low- and middle-income countries. In Mexico, 7,896 people died by suicide in 2020.

The mental health team at Compañeros En Salud is determined to provide care that saves lives.

The team includes mental health workers hired from the communities, trained on how to support patients with depression and anxiety, and dispatched to make home visits to patients with these conditions.

It was a community mental health worker, Zoemia Morales, who helped Ángel Morales understand his condition and develop a safety plan, which consists of healthy, effective coping strategies and sources of support in times of crisis—a tool used in combination with psychotherapy and medication.

“I like to learn about mental health because it is very different from physical pain,” she says. “Sometimes people do not realize that what is hurting them are their feelings and that is what I am here for—to give them a safe place where they can talk about it.”

Now, with Compañeros En Salud’s support, Morales is receiving mental health care and regaining his sense of freedom, fulfillment, and purpose.

"I thank Compañeros En Salud for supporting me," he says. "They have always supported me. Even when I stopped taking my medications, they were looking out for me. That is how I have been able to get through this."

If you or a loved one are experiencing suicidal thoughts, help is available. In the U.S., call 988 for the Suicide & Crisis Lifeline. In Mexico, call 800-911-2000 for Línea de la Vida.

Current Situation 

Haiti has faced a steadily deteriorating security situation over the past 15 months, which has worsened dramatically in recent weeks. Gang violence, protests, roadblocks, damaged communications infrastructure, and fuel shortages pose grave operational and logistical challenges for the team at Zanmi Lasante, as PIH is known in Haiti.    

At the same time, the instability leaves people at increased risk of injury and illness, of unaccompanied births, malnourishment and cholera, even more in need of ZL’s “expert mercy,” as Paul Farmer said.  

And so, despite the instability, ZL persists with unwavering support from PIH’s care coordination site. Not one ZL facility has yet closed or been forced to stop caring for patients throughout the region. Indeed, 1.3 million people, or 1 in 10 Haitians, rely on ZL-supported facilities for care, treatment and accompaniment.    

Now More Than Ever 

To assist in these efforts, PIH is focused on doing what it can to mitigate the effects of fuel shortages, reducing consumption whenever possible (in part by upgrading our facility-powering solar arrays) and limiting staff movement. On October 1, the Ministry of Health confirmed a new case of cholera; since then there have been eight cholera deaths. Working with the Ministry of Health, ZL is also helping to assess the potential for a widespread cholera outbreak and set up treatment space for acute patients, relying on the organization’s deep experience with the disease. 

 As one ZL colleague said:  

 “Haitians need us now more than ever and it would be inhuman for those of us on the ground to turn our backs. Unlike some other organizations who come to Haiti for a project or emergency and leave, PIH/ZL stays long-term to help build the health infrastructure in the long term. We’re not going anywhere and we are 100% committed to our mission." 

Led and Run By Haitians  

PIH believes a solution to the current nationwide crisis must be led by Haitians, and likely with the support of the international community. But our focus remains on working with ministries of health, not politicians; looking at histories, not the news of the day; and engaging in accompaniment and strengthening of equitable, high-quality health systems. 

ZL is of course not just an organization capable of emergency response. It is a Haitian organization, led and run by Haitians. It works with and through the Ministry of Health, serving to bolster that institution’s capacity to deliver quality health care to Haitians. Since 1985, it has only grown bigger and better, despite all sorts of political and environmental challenges. Its residency programs now train tomorrow’s leaders. In short, it is a sterling example of how to aggressively chip away at a deep, deep problem—namely, a history of oppression that has resulted in a galling lack of modern medical care in the country—through solidarity, accompaniment, and providing a preferential option for the poor. 

With a four-decade history of Haitians providing high-quality health care for Haitians, the caregivers of ZL say they will continue their work on behalf of patients, notably:  

• In 2021, ZL nurses and doctors attended to 20,220 deliveries. 
• Each month, the emergency department at University Hospital cares for an average of 700 patients for just maternal health-related reasons. 
• In 2021, ZL provided care to 2,083 mental health patients. One in five were 18 years old or younger. 
• In 2021, ZL delivered treatment for malnutrition to over 2,600 children. 
• ZL has created 190 beds for COVID care, become one of the clinical groups in the country to save the lives of COVID patients, and been invited to advise other hospitals and the national response. 
• Between July 2020 and June 2021, ZL diagnosed and treated 623 women for breast cancer.  

Medical Education, And More  

Not only is ZL providing essential services in the midst of a crisis, it also continues to strengthen health systems overall through its medical training programs. Those programs include University Hospital’s internationally accredited, top-caliber residency programs in 11 specialties—family medicine, pediatrics, internal medicine, surgery, emergency medicine, OBGYN, nurse anesthetics, neurology, plastic surgery, emergency sonography and orthopedics. 

Moreover, ZL’s response to last summer’s earthquake has grown into a long-term partnership with care delivery institutions in the south of Haiti, and it works with other health institutions in Haiti to advocate for the rights of patients and health care workers by speaking with one voice.  

Despite past and current challenges, the ZL team said it will continue to do whatever it takes to strengthen the country's health infrastructure and accompany the Ministry of Health and patients to achieve more accessible and equitable health.  

In Malawi, where residents have endured cyclones and storms followed by a cholera outbreak over the past nine months, local health teams have completed a massive oral cholera vaccination campaign in the hard-hit Neno district.  

A total of 87,352 individuals, or 59% of the district’s target population were given both doses of the vaccine, meaning they are fully vaccinated, according to a report by health workers with Abwenzi Pa Za Umoyo (APZU), the sister organization of Partners In Health. More than 86% of the population received at least one dose of the oral cholera vaccine during the campaign. 

Jones Chimpukuso, the Community Health Director for APZU), which led the vaccination efforts in collaboration with the Ministry of Health and the Neno District Health Management Team, said the vaccines provide protection against the disease for three years.  

The large-scale vaccination campaign was launched following a cholera outbreak in April that killed two people and sickened more than 300 in the Neno District, the APZU report said.  

APZU, with support from local health workers and leaders, shepherded the effort throughout, from early detection and treatment of patients to community awareness and vaccine administration. 

But the campaign required the mobilization of many in the community. For example, the APZU report noted that all 169 village heads and religious leaders in the area were briefed on the campaign and helped strategize on how to organize residents for vaccination.  

Local leaders took the vaccine in public, which sent a positive message and helped increase vaccine uptake, APZU said. Using mobile vans in densely populated regions also helped, as well as teams of health workers going door-to-door to reach families. 

Dorothy Sinkhani, a resident of the Dembe district, said the messages from local health workers convinced her to get both doses of the vaccines for herself and her young daughter. 

Cholera is a deadly disease that can cause severe diarrhea and vomiting. Children are most often affected and can quickly become dehydrated, go into shock, and die within 24 hours if they are not treated. The disease can spread rapidly, depending on the frequency of exposure, the exposed population, and the setting. The incubation period is between 2 hours and five days after ingestion of food or water contaminated by sewage bearing the bacteria, Vibrio cholerae.    

Cholera spread through the region earlier this year, in the aftermath of Tropical Storm Ana and Cyclone Gombe. The pounding rain, wind, and subsequent flooding disrupted already weak structures, including water sources, officials said. Homes across the region collapsed and most people lost their household items for sanitation and hygiene. The result: Many residents had limited access to safe drinking water.  

The storms impacted over 221,000 households and 945,000 individuals nationwide, officials said; in Neno District, more than 7,500 homes were destroyed. 

Targeted vaccination campaigns are not new for PIH: successful cholera vaccination programs were launched previously in Sierra Leone and Haiti. Indeed, PIH's work in Haiti during a 2010 cholera outbreak, rapidly mobilizing to treat more than 145,000 Haitians and vaccinate another 45,000, was key to the development of a global stockpile of oral cholera vaccines by the World Health Organization and other partners in 2012.   

Anyone seeking evidence that the current system for funding global health and other vital initiatives is failing should consider the world’s response to COVID-19. To date, there have been more than 615 million cases reported, and 6.5 million deaths, while vaccination rates have been profoundly inequitable around the world.  In a series of reports published recently in The Lancet, authors characterized the pandemic and its response as both “a profound tragedy and a massive global failure at multiple levels.” 

Now, a growing international collaborative is reimagining public investment around the world.  A new Global Public Investment Network, launched September 19 during the United Nations General Assembly, aims to move away from “an old-fashioned aid mentality” toward a new common framework for financing the most critical social, economic, and environmental challenges in rich, poor, and middle-income countries alike. According to the network’s organizers: “GPI is a co-created movement with leadership from every region of the world. It is a movement for evolving beyond aid and leveraging significantly increased international public finance to meet the common needs we all care about through the principles of ‘all contribute, all benefit, and all decide.’” 

Alicia Ely Yamin, a lecturer on law at Harvard Law School as well as PIH’s senior advisor on human rights and health policy, and Joel Curtain, director of advocacy for PIH, have been centrally involved in the development of the GPI Network. We spoke with them to find out more about the bold ideas driving this movement, including a recent article in Open Global Rights they co-authored, laying out the moral underpinnings of the campaign. 

What is Global Public Investment? 

GPI is a simple concept: all countries pay in to a pool according to ability; all receive benefits; and all have a say in how the money is spent. Global Public Investment (GPI) is about spending on global and regional public goods—common needs that transcend borders. This model shifts away from the status quo, in which decision-making is concentrated among a handful of Global North countries, to one that takes democratic decision-making seriously.   

How does GPI align with PIH’s overall mission? 

Since PIH’s founding as a social justice organization, our work has involved direct service delivery in resource-limited settings while working hand-in-hand with governments to ensure access to high-quality health care for all. PIH has simultaneously engaged in policy advocacy efforts to fight the status quo around financing health care where policy makers and world leaders have become socialized to scarcity when imagining what it will take to ensure the human right to health.

In the early days of PIH, Co-founder Dr. Paul Farmer received a MacArthur Genius Award and created the Institute for Health and Social Justice within Harvard Medical School, where he and [fellow Co-founder] Dr. Jim Kim worked together with scholars from around the world to publish books, such as "Dying for Growth," which challenged the current health and development financing structures that had become the norm in the neocolonial development financing arena. In the midst of the COVID-19 pandemic, we’ve reinvigorated our organizational engagement and commitment to advocating more deeply for structural change and we believe that the Global Public Investment principles are on the right path toward a structure of global solidarity rather than charity.  

Why is there momentum on GPI now? 

The way aid is handled now is basically as crisis-based charity; it’s politicized and counterproductive and there are huge transaction costs. GPI started as an idea a few years ago and now there’s a huge amount of attention and a window of opportunity to move toward a new model of financing. 

The world is ripe for a paradigm shift in development finance and lessons from the COVID-19 pandemic underscore that building a movement to shift that paradigm is urgent in order to advance health and other social rights.   

How did the pandemic crystallize thinking about GPI? 

COVID-19 brought the world’s attention to how desperately underfunded health systems are in much of the world. All of the other social determinants of health that shape how diverse people can manage in a pandemic or normal times, from education to social protection to digital networks, also require sustained funding and long-term investments. 

We also saw that our system of multilateral cooperation is deeply broken, and talk of “international assistance and cooperation” without changing the rules of the game are radically inadequate. In the piece published recently in OGR, we noted that: "the G7 countries’ refusal to meaningfully regulate multinational pharmaceutical monopolies or to encourage sharing of know-how and decentralization of vaccine and therapeutics production is not just morally repugnant; it undermines the well-being of the whole planet.” Instead of incentivizing technology transfers and knowledge-sharing as global public goods, “COVAX was a poorly designed emergency facility for pooling donated vaccines, which failed to meet even its dismally low aspirations for low- and middle-income countries.” 

As we noted in our article, “preventing future pandemics and advancing global health equity is inextricably tied to food security and climate justice, which in turn is also related to conflict and gender inequality.”

None of these intersecting challenges can be met through crisis-driven aid and rituals of fund replenishment; all require statutory budget assignments for sustained global and/or regional public investment from pooled international sources. 

How is PIH involved in these efforts? 

For the last two years, Partners In Health, along with many other organizations, has contributed to co-creating the GPI model because we believe it is a crucial complement to the many other efforts to promote structural conditions that underpin health and other social rights, including tax justice, debt forgiveness, intellectual property reform, and principles of rights-based economies.  .   

Realizing health for all, and responding to our global crises, requires new forms of global cooperation. These new forms of cooperation must: 1) deliver global economic justice, i.e. stop illicit extraction and unjust drain of wealth from poor countries to rich countries and 2) mobilize and distribute public resources on a global basis, i.e. global public investment. 

Why have these goals been so difficult to achieve through the current system of aid? 

The dominant narrative of aid tells us that poor countries are poor due to some inherent failing and that rich countries benevolently provide assistance to them. Not only is this untrue, but it also serves to hide the brutal reality that it is actually poor countries that develop rich ones, through unjust and illegal resource flows. What is required is justice and solidarity, not charity.  

Mobilizing and distributing public resources on a global scale requires new levels of global solidarity and requires reimagining global cooperation and the very conception of international development. Currently, the global health architecture promotes narrowly defined programs that are in misalignment with local needs, are highly fragmented, and ultimately entrench low standards of care that are deemed “appropriate” in poor settings but would be unacceptable in rich ones. This reality, in which 13 million people die medical preventable deaths each year, is a consequence of an unjust global economy and a lack of global public investment to build health systems that deliver high quality care. 

Strengthening health systems is a central pillar of PIH’s strategic plan and necessary for realizing universal health care. The principles of GPI can help with such a transformation toward a more equitable and effective mode of multilateral cooperation fit for the 21st century. 

How do you build momentum for such a movement? 

The launch of the GPI Network this week is the first step in building a movement for GPI. GPI principles are already gaining traction in policy-making, advocacy, and scholarly communities, for example  the World Bank’s new fund for pandemic preparedness and response, as well as climate finance. But GPI cannot become another tool for technocrats to discuss and deploy behind closed doors. We need a GPI movement that intersects with other progressive movements, including human rights, which are aimed at changing the structure of our institutionalized social order.

Support the Movement

A new coalition in the U.S. House of Representatives today introduced a resolution honoring the life and work of Partners In Health Co-founder Dr. Paul Farmer with an ambitious roadmap to end medically avertable deaths and realize global health equity.

The resolution calls on the U.S. government to adopt a bold “21^st century global health solidarity strategy” to end poverty, ensure health care as a human right, and address structural, economic, environmental, and colonial harms that undermine the health and well-being of people around the world. At its core, the resolution enshrines Farmer’s vision for global health equity, serving as a “North Star” for global health politics into the future.

Sponsored by Rep. Jan Schakowsky, an Illinois Democrat, Rep. Barbara Lee, a California Democrat, Rep. Raul Ruiz, a California Democrat and physician, and about a dozen original co-sponsors, the Paul Farmer Memorial Resolution is aspirational, bold, and visionary, much like Farmer, who died in February in Rwanda. Specific legislation from each of the resolution's core pillars will emerge from this effort in the near future, supporters said.

“Dr. Paul Farmer is responsible for transforming the lives of millions and millions of poor and marginalized people around the world, bringing them health care, dignity, and justice," Rep. Schakowsky said. “A true visionary, Paul insisted that all people have a right to excellent health care, and he developed the systems to deliver it in places people had written off. Gleaming world class hospitals and locally trained doctors, nurses, and community workers now exist in places like Haiti and Rwanda."

She added: 

“We are the richest country in the world at the richest time in the world. Paul called on us to understand global health inequity as an injustice—a result of centuries of violence and exploitation inflicted on the global poor. We can make the choice to end global health inequity, and with Paul’s vision guiding us, we will.”

The idea for the resolution came immediately after Farmer’s death, when his long-term supporters and admirers in Congress began discussing how to honor him and carry his vision forward. Rep. Schakowsky led the construction of the text, with input from Farmer’s colleagues at Partners In Health and Harvard Medical School.

“Paul’s long-time collaborators and global health champions in Congress wanted to honor his legacy by taking action in solidarity with the global poor,” said Joel Curtain, director of advocacy for PIH.

The Paul Farmer Memorial Resolution

The resolution seeks to put an end to “the tragic and unnecessary deaths” of more than 13 million people each year, largely the global poor, by adopting new strategies to strengthen health systems, including:

• Increasing U.S. global health spending to $125 billion per year;
• Reforming global health aid to support national health systems and direct funding to align with local plans and priorities, not the development industry;
• Creating new medical technologies for diseases of poverty and ensuring their availability as global public goods; 
• Making the global economy more fair, just, and democratic by: 1) Democratizing the International Monetary Fund [IMF], World Bank, and World Trade Organization [WTO] so that impoverished countries have equal representation and a greater say over decisions that affect their economies and their ability to finance health systems; 2) Canceling global debt for all developing countries that need it, acknowledging these debts have often been unjustly imposed and maintained;  3) Ending harmful licit and illicit financial flows from poor countries, such as global tax evasion;
• Supporting global labor rights, such as a global minimum wage;
• Proposing reparations, including award, apology, and guarantee of non-repetition of harms for the institution of slavery, colonialism, imperialism, and ecological breakdown. 

Following Farmer's Vision

In his body of work, Farmer argued our world has more resources than at any point in history. Yet, tragically, over 100 million people die every decade because they lack access to basic medical care, what he often referred to as “stupid deaths.” There is no way, he said, that we stop this injustice without ensuring the poorest countries have more resources to build health systems. To do this, he argued in much of his writing—including the books “Fever, Feuds, and Diamonds” and “Pathologies of Power”—the global community must:

• Increase global health funding to close the financing gap for universal health care, at the same time ensure this funding is used to support local public health systems, train and pay doctors, nurses, community health workers, and ensure medicines are available to the global poor, and
• Stop the ongoing economic harms to poor countries that rob them of the resources they need to provide health care for their citizens, and redress past harms and legacies of the colonial and postcolonial eras.

As Farmer pointed out, poor countries have helped develop rich countries for hundreds of years, not the other way around. We must reverse this trend as a matter of justice, he said.

A fundamental problem in global health is the low aspirations of people in power, borne partly out of a misunderstanding of the causes of and solutions to global health inequity. Farmer termed these chronically low aspirations as being “socialized for scarcity on behalf of others.”

This resolution is the most serious effort Congress has made to address this problem, Curtain said.  

Paying for universal health care

The fundamental question addressed by the resolution is: why don’t poor countries have the resources to provide universal health care?

The resolution points out that the current global economic architecture siphons resources from poor countries to rich countries.

And that this is by design, from the colonial period to today’s governance structure of the WTO, IMF, and World Bank. The resolution states: “Many of the poorest developing countries presently lack the tax capacity to mobilize the necessary resources to close the universal health coverage financing gap, meaning unnecessary deaths will continue in these settings for the foreseeable future without external donor financing or dramatic increases in domestic tax capacity.” The spending gap to achieve essential universal health care in low- and lower-middle income countries,according to the Lancet Commission on Investing in Health, cited in the resolution, is around $350 billion per year (in 2016 U.S. dollars).

Experts estimate that conferring essential universal health care in these settings would end the vast majority of medically avoidable deaths globally, preventing approximately 100 million unnecessary deaths per decade. Ensuring universal health care and strong health systems would also further protect countries currently vulnerable to pandemics. While $350 billion seems like a large figure, it represents only 0.5% of the G20 GDP in 2021,and only 2.8% of the wealth possessed by billionaires in 2021. The problem, Curtain said, is not a lack of resources but a lack of ambition.

Contrary to popular belief, the U.S. has room to significantly increase development spending; the resolution proposes increasing global health spending from $11.4 to $125 billion annually, which could come through a number of different Congressional committees, proponents said. This spending would meet around 30% of the “essential universal health care” financing gap for low- and lower-middle income countries and allow the U.S. to meet the United Nations [UN] aid target of 0.7% gross national income for the first time.

Reimagining global health

The resolution argues we should reform global health delivery spending to make sure it funds public institutions in alignment with national health plans, not private contractors in the development industry.

The resolution also asserts that the government should fund areas seldom funded in global health, like the creation of hospitals and clinics, new medical and nursing schools, and the payment of existing clinicians. It also points out that medical technologies for diseases of poverty are rarely researched; and medical technologies are also priced out of reach for the global poor. One use of the $125 billion in spending, the resolution proposes, should also be to fund an ambitious research and development program that results in new technologies available as global public goods—not kept away from the global poor behind patents, trade secrets, and market forces.

As one undeniable case in point, the COVID-19 pandemic illustrated how high-income countries’ vaccine research and development policies failed to treat vaccines as a global public good, which led to an unnecessary scarcity of COVID-19 vaccine and left millions of people without access to lifesaving tools to prevent the virus’s spread.

Support the Resolution

Partners In Health established a $200 million scholarship fund that will support University of Global Health Equity (UGHE) students in Rwanda for more than two decades, launched by a transformative $50 million gift from the Bill & Melinda Gates Foundation that was announced on September 19 at the Clinton Global Initiative in New York.

During a recent visit to UGHE’s rural campus, Melinda French Gates, the foundation’s co-chair, was inspired by students, including Eden Gatesi, an aspiring cardiothoracic surgeon. Gatesi knows the importance of quality health care; she overcame malaria during her high school finals, and her mother was a nurse who worked long hours in an understaffed clinic in their community.

“UGHE has what [Eden] needs to learn to be a cardiothoracic surgeon,” French Gates said. “What I know and what I saw is that [Paul Farmer] and Partners In Health and UGHE are building a lasting legacy on the continent. It’s for a generation of doctors who will train a generation of doctors who will train a generation of doctors. That’s what global health equity looks like.”

The scholarship fund is dedicated entirely to students attending UGHE in Rwanda. The fund, structured as an annuity, will cover the tuition, room, board, and expenses of 3,000 medical students and global health delivery master’s degree candidates over the next 25 years. The Gates Foundation is joined by the Rockefeller Foundation, the Child Relief International Foundation, and other philanthropists as early investors in the fund.

Named after the late Dr. Paul Farmer, Partners In Health’s (PIH) co-founder and chief strategist, the scholarship is dedicated to an initiative he cherished. Farmer cared deeply about UGHE and what it meant for training the next generation of global health professionals. He knew high-quality health care can only exist in tandem with high-quality medical education. This advancement of Farmer’s dream will ensure UGHE can continue to provide a top-tier health sciences education for students, who will become clinical leaders in their own right and go on to serve the most vulnerable in their communities.

“Turning early dreams of UGHE into reality has been intense and remarkable and deeply satisfying,” said Dr. Agnes Binagwaho, UGHE’s vice chancellor, who later participated in a panel discussion with French Gates, moderated by former Secretary of State Hillary Clinton. “Seeing our seventh cohort of master students in caps and gowns this summer was very exciting and knowing that, thanks in part to this fund, the university will continue for decades to graduate passionate, principled, world-class health leaders the world needs is even more exciting.”

History of University of Global Health Equity

UGHE is a PIH-led initiative which launched in 2015 with the support of the Bill & Melinda Gates Foundation, the Cummings Foundation, and the Government of Rwanda. The university is located in rural Burera District, about 80 miles north of Kigali, the country’s capital. Two miles down the road and perched on the opposite hillside is PIH-supported Butaro District Hospital, where UGHE students perform their clinical rotations. 

UGHE’s goal is to educate future health care providers and leaders who will ensure the delivery of more equitable, quality health services for all. To achieve this, UGHE provides equity-based medical training with a multidisciplinary approach to prepare students to work in vulnerable communities. The highly competitive programs—which have a 6% acceptance rate—include two degrees: a master’s in global health delivery (MGHD) and the MGHD combined with a bachelor’s degree in medicine and surgery (MBBS). Degree candidates come from 23 countries in Africa and around the globe, all receive need- and merit-based grants, and a majority of graduates are female. In 2025, the inaugural class of MBBS/MGHD students will graduate from the 6 1/2-year program. 

The Paul E. Farmer Scholarship Fund will help prepare UGHE students for lifetime learning, innovation, leadership, and research without worrying about the burden of financial barriers. UGHE’s innovative and equitable approach to health education is radically changing the way health care is delivered–in Africa and beyond.  

Before announcement of the fund, Didi Bertrand Farmer, who leads the Women & Girls Initiative and is Farmer’s widow, shared gratitude to the Clinton Global Initiative for honoring her husband and noted that UGHE students are continuing his dream of delivering high-quality health care everywhere to everyone who needs it.

Over the course of their years together, Bertrand Farmer said, “he often made impossible promises but always, always delivered on them.”

Dr. Zulema García and Dr. Azucena Espinosa have been pediatricians with Partners In Health since April. But their history in Chiapas dates back many years.

Espinosa arrived in the rural, coffee-growing Sierra Madre region in 2014, as a first-year clinician with Partners In Health, known locally as Compañeros En Salud—a year she describes as "the best year of my life."

Each year, Compañeros En Salud hosts 10 first-year clinicians, called pasantes, who complete their mandatory year of social service in rural communities where the health system has historically lacked the staff and resources to deliver quality care. Compañeros En Salud has worked in Mexico since 2011, serving nine rural communities in the Sierra Madre region, in partnership with the Ministry of Health.

After completing her year of service, Espinosa stayed with Compañeros En Salud as a coordinator for the Right to Health program. As she helped patient after patient access advanced medical care, as well as connecting them with food, housing, and transportation, she noticed a troubling reality: there were no pediatricians in the region.

Children in need of advanced care had to travel to cities hours away—journeys that many patients in the rural communities couldn’t afford.

In Mexico, medical specialists like pediatricians are often based in large cities like Mexico City, Monterrey or Guadalajara, where more advanced infrastructure and health systems allow patients greater access to care. But in states like Chiapas, one of the poorest in the country, the reality is different.

Chiapas has the lowest rate of medical specialists in Mexico, with just 35.9 per 100,000 residents, compared to Mexico City’s 505.7. To make matters more complex, there is only one public hospital in the entire state for pediatric care, located in the capital, Tuxtla Gutiérrez. Anyone outside of Tuxtla Gutiérrez in need of these services would have to travel for hours or turn to the private health system—too expensive for most patients to afford.  

That reality compelled Espinosa to pursue a specialty in pediatrics. Now, three years later, she has returned to Chiapas with Compañeros En Salud. And she was not alone.

García also began her time in Chiapas as a pasante, assigned to serve the rural community of Capitán Luis A. Vidal. She, too, stayed after her year of service, becoming a coordinator for Compañeros En Salud’s community health worker program. Compañeros En Salud’s 106 community health workers, called accompañantes, conduct door-to-door outreach in the rural communities, visiting patients and their families at home and connecting them with care.

García saw first-hand the power of community in strengthening health systems from the ground up—and the unmet need. She decided to return to school to study pediatric care. The journey led her back to Chiapas.

"I was motivated to return by the fact that I could bring a specialized service closer to the population and that they would no longer have to travel for more than three hours to reach a specialist," she says.

Now, both Espinosa and García are developing a work plan in collaboration with the basic community hospital in Jaltenango and the Ministry of Health. That plan includes training nursing staff in pediatric care, since this team is a cornerstone of care for patients in the region. Another goal is to decentralize information among health personnel and reduce gaps in patient care.

The plan has been progressing, with 20 health workers trained so far. Still, providing pediatric care in a rural area comes with many challenges, from navigating an under-resourced hospital to considering how poverty can affect a child's recovery, such preventing families from attending follow-up appointments.

But the program is already having a massive impact, in a region where there were once no pediatricians.

"Parents come up to us and tell us that in other times and in other circumstances they would not have had any option to treat their children," says García.

For Espinosa, the reward is also the sense of community at Compañeros En Salud, from staff to patients.

"It's like a family that shares the same vision, the same passion as you, and doesn't abandon you,” she says. “This is a constant reminder of why I'm here."

Electricity is non-negotiable. Yet it is simply not a reality at health centers, clinics, and hospitals around the world for a variety of reasons, principally due to years of disinvestment in local health systems scarred by war, epidemics, colonial mismanagement, and unjust global policy and financing.  

Liberia knew this reality well. When Partners In Health was invited by the national government to help respond to the Ebola outbreak in 2014, electricity at health facilities, such as J.J. Dossen Memorial Hospital in southeastern Maryland County, was unreliable. 

“J.J. Dossen had a serious power problem because all the electrical grids were very old and could not really function. There were always power outages, fluctuations of power, lots of wires getting burnt, and [electrical] shocks,” explains Eugene Cheebo, PIH Liberia’s head of maintenance. “PIH saw the need to upgrade the electrical system and now we are not having any [of those] problems at the hospital.” 

Since work began, infrastructural upgrades made by PIH and the county health team have protected against fires from corroded wires and reduced the number of patient deaths. The facility’s improved electrical capacity is allowing for better care as lifesaving procedures continue without clinicians and staff being concerned about supply.   

“Those improvements, among others made over the last several years, have had a direct impact on patients. Most notably, the death rate at the hospital has improved, according to data from the District Health Information System at the Ministry of Health, from 138 in 2016 to 73 in 2021,” says Maryland County Health Officer Dr. Methodius George.  

A Look Back

The hospital has struggled to keep the power on since its inauguration in 1960. The national grid, responsible for powering the facility, was destroyed during the first Liberian Civil War in 1990, cutting off all electrical supply. The hospital relied on a 30 kilovolt (kV) generator donated by humanitarian agencies to power the facility; but it was not strong enough to meet demand and was a major strain on the hospital’s overstretched budget. 

As George explains: “We did not have room in the budget to run a generator, so the generator was run for about four hours during the day and turned back on during the night. It was on longer during the day in extreme cases when we had emergencies that needed to be treated with electricity, especially our cesarean sections.”  

Fortunately, in 2015, Maryland County was connected to the West Africa Power Pool, which provides electricity for the hospital and some local communities. Although the power from the West Africa Power Pool has improved the situation, it has been sporadic and unreliable. The supply comes from neighboring Ivory Coast; when there are disruptions in this neighboring country, there is no local supply to tap into.

PIH added a 45 kV generator in 2016 in response to this need. Yet power from the two generators combined could only provide electricity for critical sections of the hospital, such as the operating rooms and emergency ward.  

And there was another issue at hand. J. J. Dossen Memorial Hospital’s transformer was not powerful enough to regulate the increased electrical capacity, and it frequently malfunctioned. The two problems needed to be addressed simultaneously; the power supply had to be increased to meet demand, and the hospital required a transformer big enough to regulate that increased flow of electricity. 

"The team is prepared"

With support from the Ministry of Health, J.J. Dossen Hospital acquired a 165 kV generator in 2018, but lacked funding to operate and maintain it. After consulting with the county health team in 2021, PIH offered to take on the responsibility of operating the generator to provide consistent electricity for health care delivery and the hospital’s operations. This required replacement of the old transformer with a 250 kV transformer—one with enough capacity to handle the increased flow of electricity—and total re-wiring of the facility to extend electricity supply to a long list of locations throughout and around the hospital: the surgical theater, pharmacy, eye clinic, county tuberculosis unit, pediatric unit, obstetrics and medical wards, electrical control, X-ray room, and laboratory. 

“The new generator is expected to support the facility for a few years and will continue to greatly improve patient care,” says George. “If a problem arises, the team is prepared. All technicians were trained by PIH on how to quickly and efficiently troubleshoot electrical problems by going directly to the source rather than shutting down the entire compound.” 

In the future, PIH and the Ministry of Health plan to install a more powerful transformer to further improve and support the hospital’s electrical need. Ultimately, they’d like to invest in solar power, as it’s the most cost-effective and convenient option. 

Running facilities on solar power would ultimately be good for the environment, and good for the hospital’s hometown of Harper—known locally as “the land of sunshine and happiness.”   

Originally from California, Yesenia Cuello moved to North Carolina with her family when she was five years old. As a child, she and her sisters joined their mother in the tobacco fields, harvesting leaves for up to 12 hours a day in the summer heat. This experience inspired her to speak up about the realities of working in the field.

Yesenia began fighting for agricultural worker protections as a teen when she joined Poder Juvenil Campesino, a youth group that empowers young adults to advocate for immigration reform and fair labor laws. Her time as an organizer took her from the state capital to the nation's capital, and, in 2019, Yesenia became the executive director of NC Field, a community-based organization  that supports North Carolina’s farmworker community and a partner to PIH-US, the U.S. arm of Partners In Health focused on accompanying local leaders to build strong, community-led health systems. From directly providing services that educate, build power, and address immediate social determinants of health to empowering farmworkers to pursue educational and economic opportunities and raising awareness about the injustices behind the industrial agricultural system, NC FIELD is working to ensure that seasonal and migrant workers and their families are protected and have access to opportunities beyond the agricultural industry.

Under Yesenia’s leadership, NC FIELD has grown to seven employees, added workers from the farmworker community to support interpretation and outreach, and increased its foundational support. When COVID-19 hit, NC FIELD expanded its work, offering material support to agricultural communities and setting up testing and vaccination clinics where farmworkers live, buy food, and worship. Throughout the pandemic, PIH-US has supported NC FIELD through grant writing, professional development, and data management.

Below, we talk with Yesenia about NC Field’s COVID-19 response and the challenges farmworkers in North Carolina continue to face.

What inspired you to get involved in farmworker justice? 

I was first introduced to the agriculture industry through my mom. Growing up, she worked on hog farms and then tobacco farms. One summer my sisters and I begged my mom to join her in the fields. Considering we had never worked a day in our lives, it took some convincing. She thought we would want to quit after one day––but we worked in the fields every summer for four years.

My sisters and I have always looked up to our mom. She is a single parent, passionate about those around her, and extremely independent. In our eyes, our mom was who we aspired to be. Her activist nature and the experiences of my community led me to speak up about the issues that farmworkers face.

Can you share more about NC Field’s efforts to empower the farmworker community?

In Eastern North Carolina, where NC Field is based, there are many large tobacco farms and crops such as sweet potatoes, cucumbers, and watermelon. These farms run almost entirely on the labor of farmworkers. We consider seasonal farmworkers among the most vulnerable and poverty-stricken of all farmworkers. They are a priority population for NC FIELD. Farmworkers are often exploited and suffer from malnutrition and food scarcity due to poor wages, lack of work, transportation difficulties, and rural isolation.

Empowerment is only possible when basic needs are met. At NC Field we are addressing the social barriers that keep farmworkers and their families from thriving: access to food, clothing, and health care. Not only do we go into the community and listen to the needs of workers, but we also have agricultural workers coming to us asking to volunteer and attend trainings and connecting us to vulnerable farmworkers and families that they know of.

How has your work pivoted throughout COVID-19?

NC Field is a direct reflection of the community that we serve. We listen to what the community tells us they need and adapt our work from there. To address barriers that prevented agricultural workers from getting tested or vaccinated, we set up clinics outside of typical working hours. We also went door-to-door delivering education in vulnerable communities—often in the dark, rain, and cold. These one-on-one conversations were especially important to improve vaccination rates. We found that many communities were not using reliable sources of information about vaccines, so we had to do a lot of education around the benefits of vaccination. Stepping in to support the COVID-19 response sidelined NC Field’s capacity building plans, including occupational health training and English and cultural education for the agricultural workforce, as well as our youth programming. Despite this unexpected shift, we would not have been able to accomplish all that we did without the help of the seasonal and migrant workforce. They were invaluable in helping us locate spaces for testing and vaccines, as well as helping us identify trusted messengers for community outreach.

What are the biggest challenges facing NC Field and the farmworker community as we enter year three of the pandemic?

For NC Field, it is financial sustainability. We are now providing all types of services that farmworkers have come to rely on––from vaccines and health care, to access to food and clothing. It has been hard to look beyond COVID-19, beyond a temporary response team. We want to be able to establish long-term infrastructure and provide job security for our staff.

For the farmworker community, transportation and access to health care remain big issues. We are working with partners to expand the days and hours that health centers are open, as well as the services they provide. Having health education, news, and other critical information accessible in a variety of languages is also important. Many parents rely on their children to translate. It is unrealistic to expect children to accurately process and relay the type of information they are being called upon to support with. And honestly, it's just not fair.

How can we continue to build power in the agricultural worker community?

We need to keep the focus on vulnerable groups at the state and federal levels so that we don’t return to the period of anonymity and invisibility that farmworkers had before the pandemic.

Because of the partnerships we have built over the last few years, NC Field is sitting at tables where, historically, we've never been. In many of these conversations I am the only person who is a current or former farmworker. This isn’t enough. We need to push for adequate representation at these tables. Afterall, who better to share the realities of issues impacting the agricultural workers than the communities themselves?

My hope is that generations of child farmer workers and their families have the same opportunities that I had.

What makes you hopeful about the future?

Education, information, and advancement opportunities all give me hope. We’ve lost so much in my community. So many of us can’t legally drive to work, but we are harvesting this nation’s food supply; we struggle to access doctors and surgeries. Some of us are guest workers and live in housing that can’t be reached by first responders.  There is a lot wrong. Despite all of this, I see smiles and helping hands at every food distribution event, at every clinic, and as people are picked up and dropped off at appointments or the grocery store. I see hope. We are given hugs, and thanked for the medicine we delivered, the donated mattresses, and the driver’s license manuals we printed off in Spanish. We have learned to endure as resources arrive that teach us how to navigate languages, culture, and systems. I am hopeful because my community is strong, and we will persevere until we are truly equal—and then we will thrive. 

Oxygen is one of many critical building blocks of a functional and equitable health system—like running water and 24-hour power. Yet most medical facilities in low- and middle-income countries lack access to this crucial resource.

Effective treatment with medical oxygen requires the right amount at the right time, with close to zero margin for error—oxygen shortages lasting just 30 minutes can be catastrophic. Oxygen insecurity means that all it takes is a power outage, mechanical failure, or surge in patients for oxygen supplies to run out. 

Although this sounds complex and challenging, there is a solution: investing in the “five S’s”—the staff, stuff, space, systems, and social support needed for strong health systems. These investments save lives. For example, building and strengthening oxygen services for children under 5-years-old with pneumonia reduces the odds of disease-specific mortality by an estimated 46%. But the impact of improving oxygen systems extends beyond any single disease. It is also associated with a 40% decrease in the odds of death for all children in the hospital.

The global oxygen crisis must be addressed. While the COVID-19 pandemic highlighted regional disparities in oxygen access, it has been a longstanding issue. Before the pandemic, 9 in 10 hospitals in low- and middle-income countries lacked access to oxygen therapy.

To accelerate efforts to overcome oxygen-related barriers and in partnership with funder Unitaid, Partners In Health (PIH) launched BRINGO2, a yearlong oxygen systems strengthening initiative in Peru, Malawi, Lesotho, Rwanda, and Madagascar. BRINGO2 is helping fight the global oxygen crisis by supporting the repair and maintenance of piping systems and cylinders, training technical and clinical staff, and planning long-term oxygen distribution networks, among other efforts. So far, significant improvements have been made across countries: a high-tech remote monitoring system was installed at the Botsabelo pressure swing adsorption (PSA) plant in Lesotho, biomedical technicians repaired 76 oxygen concentrators in Malawi and are actively repairing 20 PSA plants in Peru, and a new PSA plant is being installed at Butaro District Hospital in Rwanda.

LEARN MORE

The comprehensive initiative involves every aspect of oxygen’s complex journey. In the infographic below, learn how oxygen makes its way–from production to bedside–to those who need it most.

Hugs and kisses weren’t always part of Carmen Dávalos' daily routine with her daughter. But now, the 35-year-old mother takes every opportunity she can to shower her daughter, Yeretzy, with affection.

No one had ever taught Dávalos, who had her first child at 18 years old, the importance of showing affection in a child’s development. It was a lesson she learned from Socios En Salud, as Partners In Heath is known in Peru, as part of the CASITA program.

Socios En Salud has worked in Peru since 1994, when it responded to a deadly outbreak of multidrug-resistant tuberculosis. In the years since, it has expanded its work to provide medical care and social support to hundreds of thousands of patients in Lima and beyond.

Since 2013, Socios En Salud has supported children and caregivers through CASITA—a three-month program that identifies children ages 6 to 24 months who are at risk of developmental delays and helps them learn skills through play.

CASITA has enrolled 3,648 children and screened 6,795 since it began in Carabayllo, a district in northern Lima where high rates of poverty and domestic violence put children and their health at risk. Eighty-five percent of children showed improvement during the pilot program, which supported 180 families from 2013 to 2016.

Dávalos heard about CASITA last year, as she received follow-up care at La Flor clinic through Socios En Salud’s support. Staff had observed that Yeretzy, then a little over a year old, was very shy, fearful of others, and lacked the social, motor, and coordination skills of most children her age. They encouraged Dávalos to fill out a screening questionnaire for the CASITA program via chatbot.

Just a few days later, María Berrocal, one of 262 community health workers hired and trained by Socios En Salud, visited Dávalos and her daughter at home to carry out an evaluation, using games such as building a tower of cubes and playing with puppets to assess Yeretzy’s skills. Berrocal determined Yeretzy was eligible for the program and helped Dávalos join a WhatsApp group for caregivers.

Then the classes began.

Each week, Dávalos and other caregivers in the program received a recorded lesson to review and practice with their children at home. The classes covered a range of topics—motor skills, coordination, social skills—and incorporated games like hide-and-seek and toys made from household items. Dávalos completed the lessons with Yeretzy, often with the help of her husband and three other children.

With each lesson, Dávalos watched her daughter grow her skills and confidence. Yeretzy learned to tear sheets of paper. She built a tower of cubes and organized the pieces according to size. She imitated the sounds and actions of her mother.

Dávalos shared photos and videos with the WhatsApp group to document Yeretzy’s progress and receive feedback.

“Every week, we could see how she progressed,” says Berrocal.

Yeretzy wasn’t the only one learning.

“It has taught me a lot,” says Dávalos. “Hugs and kisses and caresses should never be missing. We must always show them without shame and attend to [our children's] needs.”

She began to sing for her daughter—something she had once been too embarrassed to do.

“Seeing the mothers in the WhatsApp group singing to their children…motivated me to do it,” she says. “I managed to sing in my house in front of my whole family, without problems or embarrassment.”

She hadn’t always felt so free.

Her pregnancy with Yeretzy began in December 2019, just months before COVID-19 sent the nation into four months of lockdown. She caught the virus in June, six months pregnant and unvaccinated, isolating her at home and sending her into a deep depression.

During that time, Socios En Salud continued to provide maternal health care, monitoring her pregnancy virtually, and connected her with mental health care, including therapy. That support came as a lifeline for Dávalos—and it continued after her daughter was born.

Early detection of developmental delays is crucial in helping children access the care and support they need to become healthy, independent adults. But the pandemic, marked by quarantine, social distancing and disruptions in care, complicated efforts to identify at-risk children, even as it hamstrung their development.

Only 28% of children under 36 months are up to date on their growth and development checks due to the pandemic, according to Peru’s Ministry of Health. More than half of children between 9 and 12 months old have not developed an adequate bond of trust, security, and emotional stability with their mothers.

Lesson by lesson, Dávalos was determined to defy those odds.

“Every week, with each game, I was able to connect with my daughter,” she says.

Now, Yeretzy is no longer scared. She smiles at strangers. She laughs and poses for the camera. In Berrocal’s words: “She is pure joy.”

Dávalos has only to look at her daughter’s face to see the difference.

“She is everything to me,” she says. “Seeing her now, as a happy and fulfilled child, is what fills my heart the most.”

The Inflation Reduction Act might not sound like legislation that has anything to do with health equity or addressing disparities in the United States. The name suggests that it will handle the costs of groceries and gasoline. But it goes much further by helping make health care more affordable for millions of people. This legislation, however, did not come to pass easily, and Partners In Health has been tracking it and supporting parts of the bill for nearly a year.  

In late 2021, the U.S. Senate failed to pass the Build Back Better Act (BBBA), the $1.75 trillion package that would have transformed health equity, green energy infrastructure, and U.S. health care, after the sweeping bill had passed the U.S. House of Representatives. This was a disappointing turn, as PIH supported the BBBA due to its inclusion of funding for maternal health, community health workers, and coverage for low-income families.  

Senators continued to negotiate a smaller version of the BBBA with the hopes of reaching an agreement on the pieces that could garner enough support to pass. In July, they announced an agreement on the newly dubbed Inflation Reduction Act.  The bill quickly passed the Senate on August 7 by a vote of 51-50 (with Vice President Kamala Harris breaking the tie) and the House on August 12 by a vote of 220-207, before being signed into law by President Jospeh Biden on Tuesday.  

Below, PIH-US Advocacy Manager Lucas Allen and PIH-US Advocacy Lead Justin Mendoza explain what there is to be excited about with the passage of the Inflation Reduction Act, who will benefit, and why it falls short in the battle for health care equity.  

What does the Inflation Reduction Act include? 

• Health insurance premium support: Through the American Rescue Plan Act of 2021, Congress enhanced the Affordable Care Act’s premium tax credits so that more people could obtain affordable coverage. Those tax credits lowered monthly costs for people who purchase their insurance from a private market place. Set to expire at the end of this year, it was critical to include the premium tax credits in the Inflation Reduction Act or millions would face increased health insurance costs and potentially lose coverage. The legislation extends these enhanced credits through 2025. 
• Lower-cost prescriptions: The Inflation Reduction Act will require Medicare to negotiate the prices of certain prescription drugs starting in 2026. It also caps out-of-pocket drug costs for people enrolled in Medicare and penalizes drug companies if they increase Medicare drug prices faster than the rate of inflation. For millions of people in the U.S., this policy will mean being able to afford their prescriptions, and for the U.S. itself it means working to rein in high and rising prescription drug costs. This is historic, since Medicare negotiation has been out of reach for the past 18 years.  
• Investments to address climate change: The Inflation Reduction Act includes $369 billion to reduce greenhouse gas emissions that contribute to climate change and related health impacts. This is the biggest investment in combatting climate change in U.S. history. 
• No anti-migrant amendments: PIH leaders have been advocating forcefully against Title 42, an unjustified and racist policy that uses public health and the COVID-19 pandemic as a pretext to block asylum-seekers from entering the U.S. Two amendments were proposed to the Inflation Reduction Act that would have further extended Title 42. Before the votes, PIH reached out to urge senators not to support such amendments, both were narrowly defeated, and the final bill did not include any anti-migrant policies. 

Who benefits most from passage of the bill? 

Right now, 14.5 million people in the U.S. get their health care from their state or federal health insurance marketplace. For millions of lower-to-middle income families or individuals, this policy will keep their current health insurance affordable. The health care credits also make insurance more accessible for Black and Latinx communities. Since these credits have been in effect, Black and Hispanic enrollment saw an increase in number of people willing to enroll in health insurance as compared to previous years. Maintaining these credits will be a big boost toward continuing to close the gap in health coverage and access to care. 

A senior citizen enrolled in Medicare will see relief in drug costs once Medicare has the ability to negotiate down the costs of high-priced drugs. A Medicare beneficiary who spent a significant portion of their income on prescription drugs will have their out-of-pocket costs capped at $2,000 per year. Today, more than half of seniors aged 65 or older take at least four prescription drugs, and nearly 1 in 4 of those seniors say it is difficult to afford their prescriptions. Particularly hard hit are low-income seniors and those who are in poorer health. This policy will save most of these seniors hundreds or thousands of dollars per year.  

The bill’s historic investments in addressing climate change will benefit the health and well-being of all who face risks from the climate crisis. By putting the U.S. on a path to reducing greenhouse gas emissions by 40% by 2030, this legislation is a step toward reducing the health impacts of climate change, which fall disproportionately on communities that have been historically marginalized.  

Where does the Inflation Reduction Act fall short?  

The Inflation Reduction Act is a compromise, and it does fall short in areas that PIH fully supports. We strongly encourage congressional leaders to take up these priorities as soon as possible to focus on health equity in the United States. 

• Closing the Medicaid coverage gap: The Inflation Reduction Act left out a provision that would have provided health coverage to low-income adults in states that have not expanded Medicaid,  a state and federal shared insurance program that provides health care coverage to low-income families. This would have provided health insurance to an estimated 2.2 million adults whose income is too low to be eligible for Affordable Care Act subsidies. 
• Maternal health: The Build Back Better Act also included policies to address the maternal health crisis, which disproportionately affects Black women. It would have required all states to extend Medicaid coverage to 12 months postpartum, which is currently optional, and it would have provided funding for Black maternal health across multiple agencies in the federal government. The bill did not include these provisions, leaving a gap in maternal health. 
• Child and family supports: Previous legislation, the American Rescue Plan Act, included a child tax credit that temporarily reduced child poverty by about half in the United States. In addition the BBBA included support and investments for child care. This bill did not include either of these provisions, leaving low-income children and families without essential evidence-based support. 
• Public health infrastructure: The Inflation Reduction Act also missed an opportunity to invest in the U.S.’s public health infrastructure and workforce to better address COVID-19, monkeypox, future outbreaks, and other health needs. Despite previous efforts in the American Rescue Plan Act and other COVID-19 relief legislation, public health resources for pandemic response are a far cry from what is needed to deliver an equitable public health system. 

While it is disappointing that these critical priorities were left out, the Inflation Reduction Act makes important investments in health and climate that will make a significant difference in people’s lives. Congress still has work to do to meet these critical needs for health equity, and PIH will continue to push for our health equity priorities. 

One year ago, a 7.2-magnitude earthquake struck 80 miles west of the capital of Port-au-Prince, Haiti, leaving more than 2,200 people dead, 1,800 injured, and hundreds of families displaced. Authorities reported that 97 health centers and 1,250 schools were damaged or destroyed in the powerful quake, which had an epicenter near the cities of Les Cayes and Jérémie.

Zanmi Lasante, Partners In Health’s sister organization in Haiti, does not work in the region, but partners in the Ministry of Public Health and Population and non-government organizations in the South reached out to ask for assistance in launching a comprehensive emergency response, knowing Zanmi Lasante's depth of experience in critical care and effective response to the 2010 earthquake. Together, they provided direct care and support in the region, triaged complicated cases to neighboring hospitals, and, in some cases, airlifted patients to Zanmi Lasante’s Hôpital Universitaire de Mirebalais (HUM).

Unlike the devastating earthquake of 2010, the vast majority of first responders and clinicians in the 2021 response were Haitian—including graduates of HUM.

Emergency Response

Over the past year, Zanmi Lasante has:

• triaged and treated 67,658 patients from the earthquake zone with severe conditions, including those requiring orthopedic surgery, at HUM
• served 36,825 patients through multiple mobile clinics staffed by physicians, nurses, medical residents, and psychologists
• provided 3,113 survivors with psychosocial assistance, including food, hygiene products, and school materials
• sent 209 medical items and equipment, including portable ultrasound machines, to support hospitals in the South

This was all done despite significant challenges: gang violence prevented regular travel along a major route between the capital and the southern peninsula, gas shortages forced rationing across the 16 public health facilities supported by Zanmi Lasante, and COVID-19’s spread remained a concern nationwide.

Building Health Systems

As weeks turned to months, Zanmi Lasante and partners shifted from emergency response to medium- and long-term planning that focused on reinforcing the public health system—both at facilities supported by Zanmi Lasante and in the South—so that the next disaster might have less of an impact.

Within that stream of work, Zanmi Lasante has been supporting the construction of a surveillance lab and emergency ward at Hôpital Saint-Nicolas in Saint-Marc and reinforcing emergency and trauma staffing to respond to growing need for these services in the lower Artibonite region. The team is also making targeted improvements to water, sanitation, and hygiene infrastructure within all 16 of its supported health facilities—key to preventing water-borne illnesses that often come in the wake of natural disasters, such as hurricanes and floods.

Meanwhile, in the South, Zanmi Lasante teams continue to provide essential medical supplies and equipment across the earthquake-impacted regions, while also supporting the construction of three permanent health centers.

Focus on Medical Education

Last August’s earthquake highlighted the need to develop more opportunities for specialized training in Haiti, especially orthopedic and emergency residency programs for clinical nurses. Zanmi Lasante leaders are now mapping out curricula for these programs, which they plan to launch in October at health facilities in Saint-Marc and Mirebalais.

Eventually, these residencies will add to a suite of options available at Zanmi Lasante-supported facilities, including HUM, which received international accreditation in January 2020 for meeting the highest global standards as a teaching institution.

Since 2012, HUM’s medical education program has trained 152 Haitian clinicians across specialties, including family medicine, pediatrics, internal medicine, nurse anesthesia, surgery, emergency medicine, and OBGYN. HUM also offers fellowships in neurology, plastic surgery, and emergency sonography.

Of those graduates, 98% currently work in Haiti, with 88% working in PIH-supported or other rural health facilities.

Dr. Marta Lado still remembers the early days of the Ebola outbreak in Sierra Leone—how patients needlessly died of the disease and suffered stigma, discrimination, and lack of access to lifesaving medical care. Now, the infectious disease specialist is watching some of those same patterns repeat with monkeypox.

While not usually fatal, monkeypox has led to more than 28,000 cases worldwide. Typically confined to West and Central Africa, the disease has since spread to 81 countries where it was not historically detected. Monkeypox is known for painful lesions and rashes and is usually spread through skin-to-skin contact.

PIH has responded to infectious diseases for decades, from HIV to Ebola to COVID-19. Lado is no stranger to outbreaks either.

Now PIH’s cross-site clinical advisor, Lado was formerly chief medical officer with PIH Sierra Leone, where she helped lead the response to Ebola in 2014 and was integral to caring for patients, fighting stigma, and building up the health system in the years that followed. Lado has also brought her expertise to the World Health Organization as a case management expert and in 2019 authored Ebola Virus Disease: A Manual for EVD Management.

Drawing on her years of experience fighting infectious diseases, Lado shares her insights on monkeypox—and what must be done.

Monkeypox isn't a new disease. It's been around since the 1970s. What’s so alarming to you about this current outbreak? What are we seeing that we haven't seen before?

There are two main points that we should be bringing up. One is we have had reports of monkeypox in several Central African and West African countries since the 1970s, and it was more localized in those regions. This is the first time that we are seeing very intense, rapid community transmission in countries that normally had never been affected by this.

This is exactly what global health implies: it's not like this disease is happening in one region and it's not going to affect me at any point. With Ebola, with COVID, and other things, we are seeing that this idea of creating regions to divide diseases is not valid anymore. We are living with globalization in terms of movement of people and this is also going to affect health.

The second point is that the clinical presentation that we are seeing right now is a different from what we historically saw in Central and West African countries. Normally, in these endemic countries there were symptoms like fever, weakness, headache, myalgia, and then one rash that started in the face and went to the trunk. [The virus] disseminated quite fast and in certain populations like children and the immunosuppressed.

This was the picture that we had of monkeypox until now. Now, in the outbreak that started in Europe and disseminated everywhere, what we are seeing are symptoms more localized in one region [of the body]. So that's why we are seeing a lot of infections that happen in the context of sexual contact or very close contact. We’re seeing lesions in the parts of the body that have been in close contact with the person who was infected.

PIH has responded to many pandemics and epidemics around the world, and monkeypox is just the latest virus to capture global attention. What are some of the lessons learned from our past responses that could be relevant and useful now?

There are two main outbreaks that we worked on—one was Ebola. What we can learn from our Ebola experience is that the work to prepare and respond to any kind of health emergency like this is based on comprehensive work between different teams. We need to be focusing our attention on surveillance—being able to identify potential cases and doing contact tracing and follow-up. We also need to focus on diagnosis. We have learned a lot [from Ebola] about how to do testing. Then there’s case management. We have learned quite a lot about how to manage diseases that develop complications and how to care for patients who develop shock, multiple-organ failure, superinfections, etc.

Then lastly, community engagement. We have been extremely good in our Ebola work at sending messages to the community and receiving feedback, as well as reducing the stigma against Ebola survivors. So these four main pillars are extremely important: contact tracing, testing and laboratory capacity, case management, and community engagement.

With COVID, our work [across these four pillars] has excelled even more. Paul was always repeating that we need to be able to deliver the same standard of care in low-income countries and high-income countries. If a patient is in a critical condition, we need to be able to strengthen the [health] systems to manage them. With monkeypox, a very small amount of patients get very sick. It's not as much as in COVID and even much, much less than Ebola. But it's still killing quite a lot of people in African countries.

Diseases like monkeypox have affected impoverished countries for years, even decades, with hardly any attention from the West. What do you make of this sudden urgency around monkeypox? How does global injustice factor in?

We are now living in a moment of great awareness of infectious diseases. We have information in real time about what is happening in different countries—like whenever you have a cluster of cases in this country, you are able to receive information about what is going on in neighboring countries or even very remote countries. I think it’s a positive thing, because it means that we are creating more surveillance and more detection.

But as a global health specialist, I strongly think that we also need to start involving more countries that have been suffering these diseases for longer periods, but didn't have strong scientific communities or health care systems to deal with them in the same way as high-income countries. Monkeypox has been not only a threat but a reality for many countries—people getting sick and dying and vaccination programs and treatments and everything being delayed. When it started happening in high-income countries, everything got triggered and now it's a big thing and everything is accelerated.

I tend to look at the positive side, which is: let's use this as an opportunity to advocate for the development of all these different elements, like surveillance and treatment and community engagement, so we can extend them to other countries that don't have as strong of health care systems. The more we improve our laboratory and surveillance capacity, the more we will start seeing more cases in low-income countries. We will need to have all these things ready to be able to help them deal with it.

With diseases that are spreading globally like this, we’ve often seen marginalized communities blamed and stigmatized. We saw this with HIV/AIDS, Ebola, and COVID-19. We’ve seen this same trend start to happen with monkeypox. How do we spread awareness about this disease while also fighting against stigma and discrimination?

One of the things we need to acknowledge is that the first cluster of cases started in one specific community—gay and bisexual men. This is quite tricky because it can lead to stigmatization and to associating the disease with this population. We have a bunch of cases in this community, but there is no clear evidence that it can only affect this population. The spread in this community has been very fast and the infection rate has been quite high in terms of number of contacts. But we don't have any evidence to think that this cannot go to other populations, like children, pregnant women, patients with chronic diseases, etc.

We need to be very careful with how we are communicating about this monkeypox outbreak, because it's very easy to repeat the mistakes that we made when HIV emerged in the ‘90s. Now, we all know that HIV can affect anyone; it's not related to your sexual preference. It’s more related to some kind of sexual contact. We know that monkeypox is transmitted by close contact. But it could also be transmitted by droplets—it could stay in the air and be inhaled. This is not only a sexually transmitted infection. It is an infection that is transmitted face-to-face and skin-to-skin and needs to be taken as that.

PIH has been calling for vaccine equity for decades for many different diseases and conditions. How is the issue of vaccine equity showing up with monkeypox?

The vaccines that are available for monkeypox were actually created for smallpox. After the eradication of smallpox in 1980, the quantities produced were quite small because the idea was that there could be some kind of bioterrorism threat. So those vaccines were produced, but with the idea of keeping them within the government. The thing is, smallpox and monkeypox are very similar. They belong to the same family, and the smallpox vaccine has around 85% efficacy against monkeypox.

Scaling up production of these vaccines may take time. It’s important to engage in advocacy. Vaccine production is not only about the current outbreak. There are several countries that have cases on an annual basis, and we need to produce more vaccines to be able to control the rate of infections.

In terms of equity, we’re in a moment where we have only a small amount. So we need to select which populations to prioritize. The populations that were prioritized historically were health care workers. But now, in the current outbreak, there is general concern and calls for advocacy to create more vaccines. Right now, we have one specific group with the infection, but the moment it starts spreading to other groups, we are going to need more vaccines. So our advocacy needs to go for increasing the production to be able to cover as many groups as possible.

Right now, the global conversation around monkeypox seems to be focused on vaccines or educating the public. How do you see the global response to this developing—what's the next chapter, and how do you see PIH being part of that?

Right now, the response is focused on specific countries and on a specific population. But we forecast that this may start affecting different populations and spreading more widely. It will be important to get clear guidance on who to vaccinate, who to treat, and what drugs to use for both, as well as to have these treatments accessible to all for free.

The way that I see PIH working is in advocating for equity and communicating that this is an infectious disease that could affect anyone. Right now, it's in a specific group, but it could extend to other groups very soon. So we need to increase awareness and continue advocating for surveillance, testing and laboratory capacity, case management, and community engagement. Also, as an organization that works mainly in low-income countries, we need to raise our voice even more to ensure that there is equitable access to medications and vaccines.

As PIH, we need to continue supporting the most vulnerable. And we need to think longer term about what happens if this starts becoming more global, and we start identifying more cases in the countries where we work.

When Dr. Afom Andom, chief medical officer at Partners In Health in Lesotho, noticed blank spaces and other discrepancies in several district tuberculosis (TB) registries in 2020, he was perplexed. 

As a former health reform technical advisor from 2016-2019, Andom quickly realized that local TB screening programs were not going well. He and several colleagues in Lesotho and globally sought to find out why.

In a new study, published in PLOS Global Public Health in March, Andom, who graduated from Harvard Medical School, Department of Global Health and Social Health in 2021 found that numerous barriers stood in the way of TB screening, with dire consequences.

“If we do not screen, we are not going to diagnose and thereafter treat TB,” said Andom, the study’s lead author, adding that, “Undiagnosed people live in the communities and continue to spread the disease.”

TB is one of the oldest infectious diseases, but these days it is far more prevalent in resource-poor countries and regions. Globally, around 30% of people with TB are neither diagnosed nor treated. Lesotho has the highest TB incidence globally with an estimated 654 cases per 100,000 for a population around 2 million. Due to the double burden of HIV, 62% of TB patients are co-infected with HIV. Timely detection through quality screening is need improve treatment rate, reduce mortality, and control transmission.

Patients Speak Up

For the study, Andom and his colleagues interviewed 24 patients at two facilities in the Berea district, Berea Hospital and Khubetsoana Health Center. The patients shared their experiences accessing TB services, noting numerous barriers. Many patients take public transportation; therefore, they need to wake up in the early morning to walk and catch the taxi. The taxi rides are long in distance and in time as the taxi will continuously stop and go, picking up passengers along the way. Finally, once the patients arrive at the clinic or hospital, they are greeted by long queues and can expect to wait half a day until they are seen by a clinician. One of the nurses interviewed stated, “once a patient has any TB symptoms, he/she is ordered to send the sputum to the TB clinic so this makes patients unwilling to give out all the answers when being screened.”

“We have a great problem. A person is already very sick, like I have told you that sometimes I even struggled to have food, I have already left home having not taken enough food. When you get to the facility, you get here at 8:00 am only to get consultations at 12 [noon],” a patient at Khubetsoana Health Center, who was quoted in the study, said.

Many patients shared that they hide their symptoms because they want to finish early and go back to their villages. Andom and his colleagues found that patients are sometimes screened twice in the same visit, prolonging the time they spend at a facility. Combined, these reasons indicated flaws in the screening process which leads to patients leaving the clinic or hospital undiagnosed with TB.

Health Workers’ Screening Burden

Makena Ratsiu, Berea District’s primary health care coordinator with Bo-mphato Litsebeletsong Tsa Bophelo—as PIH is known locally, said one aspect of the research, in particular, surprised her: health care workers find TB screening as one more task added on top of an already overwhelming scope of work, and so it does not receive adequate attention. Afom and his colleagues found that in the facilities nurses were not designated to carry out TB screening and that screening activities are shared among staff. Study authors discovered in their interviews with health care professionals that clinics and hospitals are frequently understaffed compared to patient demand; TB screeners lack adequate training; and multiple individuals are asked to screen, although it is not their primary role. “Ultimately, this means patients living with undiagnosed TB subsequently suffer,” said Ratsiu.

Ratsiu said this has been an eye opener for her and she can see where she needs to apply more effort when she visits various facilities for mentorship. To improve TB detection, all healthcare workers need TB education to properly screen for TB. TB screening education is a must. Additionally, Ratsiu mentioned that there should be follow-ups to see whether screening is done according to guidelines.

Low Screening Rates

Andom and colleagues found that of the 70,393 visitors from the two facilities studied, only 22% of hospital patients and 48% of health center patients were screened for TB. They discovered that out of those who were asked about TB symptoms, only 2% revealed their TB symptoms. This is a very low number in a country with the highest TB statistics.  The data reveals that there is a lot of work to be done to improve TB screening, researchers said, and the findings can help with the integration of better health services and also advocate for funding. “Sufficient and equitable staffing, adequate supply of essential commodities, and proper monitoring and evaluation of performance though effective data utilization is critical for eliminating TB,” Andom said.

Next Steps

As a result of the study, PIH has enhanced its support to the Ministry of Health by building capacity in TB screeners; which has resulted in identifying screening gaps and remedies to address screening needs. Additionally, PIH Lesotho has expanded TB screening and diagnostic services by equipping facilities with digital x-ray machines and teleradiology and new mini labs, along with the technical staff to manage and safeguard it.

Meanwhile, Andom is now studying the barriers of TB diagnosis and treatment and the impact of COVID-19 in TB in Lesotho. To improve TB treatment outcomes, he hopes to better understand challenges around drug adherence and other issues preventing patients from being cured.

Ludentz Dorcelus clearly recalls the “complete chaos” that overwhelmed his hometown of Port-au-Prince after a 7.0 magnitude earthquake devastated Haiti in 2010, killing some 300,000 people. Dorcelus, 18 at the time, was one semester short of graduating high school when the quake, which leveled the capital city, hit.

In order to finish school, Dorcelus and his parents agreed that he would move to the U.S., to the home of an aunt and uncle, in Nanuet, NY—a small town about 30 miles north of Manhattan. There, he graduated, then returned home and passed the local exams to complete high school in Haiti and apply to college, settling on a career in medicine. Now, Dorcelus is in the final year of his residency: he plans to stay in Haiti and practice family medicine.

Education was a focus of his family, Dorcelus said, so it’s not surprising that when it came to structuring a research project as part of his medical school “social service” year, his hypothesis was that education was closely correlated with adherence to medication protocols. “A lot of that was based on my own experience,” he said.

However, the results of his research, which looked specifically at adherence to antiretroviral therapy (ART) at one hospital in Haiti and was published in the journal AIDS Research & Therapy last November, undermined that theory. For Dorcelus, the study’s lead author, that finding came as a “big surprise.”

Research Findings

The study included 411 patients at St. Therese Hospital in Hinche, a public facility in central Haiti, which is also supported by Zanmi Lasante, Partners In Health’s sister organization. Zanmi Lasante, founded in the early 1980s, now comprises a network of 15 clinics and hospitals in some of the country’s most impoverished regions and serves more than 1.3 million people.

Researchers, relying on self-reported patient data, found that age and the ability to meet basic needs were the only two factors that significantly correlated with adherence. “The odds of having poor adherence was significantly higher in patients under 40 years compared to those 40 years of age and older,” the study concluded. Additionally, it found: “Patients who could not meet their basic needs were more likely to have poor adherence.”

Earlier research has also found that younger patients can have more trouble following medical protocols in similar settings, Dorcelus said. That body of work suggested that older patients were more accustomed to the routine of medical regimens: “The survival instinct was also mentioned in these studies: the elderly patient, in decline, recognized that their life expectancy would be prolonged through good adherence.” At the younger end of the spectrum, “adolescents and young adults were at increased risk of treatment failure due to multiple social, psychological and adherence barriers,” the recent study had found.

Better Outcome and Survival

Adherence matters when it comes to all medications, but in particular, it’s associated with better outcomes and survival among people living with HIV, the study noted.

To be sure, most patients in the study —a full 82%— reported their adherence to ART was “excellent.”

Among those who reported poor adherence, the reasons varied, but many of them stemmed from general poverty: “Only 9% said they could always meet their basic needs compared with 27.9% who could never meet their needs. Not being able to meet their basic needs was associated with almost three times greater odds of poor adherence.”

The study noted that ART is free in Haiti. “Were treatment not free, it would likely pose an even greater barrier to treatment adherence,” the study said. “If they [patients] do not have enough resources for food, they are likely to be more focused on solving this immediate need, instead of achieving viral load suppression. It is also a common belief amongst Haitians that medication should not be taken on an empty stomach. Living in poverty, not having access to water/food may prevent them from taking their medication.”

More Studies Needed

And while other studies have shown a link between education and adherence, this one did not. The literacy rate in Haiti for those 15 and older is 61%, the study noted, and the Central Plateau region has the nation’s highest illiteracy rate. “Surprisingly,” the authors said, “we found no statistically significant difference between adherence among those that had been schooled compared with those who had received no schooling.” However, they theorized that given the high illiteracy rate and limited ability to meet basic needs, “it is likely that access to education could potentially improve adherence to ART in this area.”

Overall, Dorcelus said, more studies— at more hospitals— are needed to figure out all of the complex elements that drive adherence. “We need a nationwide study or a larger study to figure out the other barriers,” he said.

The Importance of Social Support 

Dorcelus’ driving curiosity in the research struck Mary Clisbee, provost for academic affairs and research at the University of Global Health Equity in Haiti. "What I find most amazing is that he recognized the problem, searched the literature, and developed the study on his own, and during his service year!" Clisbee said. "That is unheard of! His level of motivation and autonomy is remarkable."

Dr. Ornella Sainterant, director of medical education at HUM adds: "This study proves once again Dr Paul Farmer's teaching on social medicine [and] medical humanism: Our treatment won't work without social support."

For now, Dorcelus said he is working on another project looking at the factors linked to poor glycemic control in diabetic patients, while also finishing up his studies. Though his future career path is not clear at this point, one thing is certain.

“Even though the situation is bad, people are fleeing the country, and we are living in constant fear,” he said, “I grew up in Haiti. I want to stay here and serve my population.”